This site uses cookies to deliver our services and to show you relevant ads and presentations. By clicking on "Accept", you acknowledge that you have read and understand our Cookie Policy , Privacy Policy , and our Terms of Use.
X

Download Allergy and Asthma-Improving Outcomes in Primary Care PowerPoint Presentation


Login   OR  Register
X


Iframe embed code :



Presentation url :

X

Description :

View and free download Allergy and Asthma-Improving Outcomes in Primary Care powerpoint presentation which is uploaded by honey an active user in belonging ppt presentation Health & Wellness category.

Tags :

Allergy and Asthma-Improving Outcomes in Primary Care

Home / Health & Wellness / Health & Wellness Presentations / Allergy and Asthma-Improving Outcomes in Primary Care PowerPoint Presentation

Allergy and Asthma-Improving Outcomes in Primary Care PowerPoint Presentation

Ppt Presentation Embed Code   Zoom Ppt Presentation

About This Presentation


Description : View and free download Allergy and Asthma-Improving Outcomes in Primary Care powerpoint presentation... Read More

Tags : Allergy and Asthma-Improving Outcomes in Primary Care

Published on : Dec 06, 2013
Views : 558 | Downloads : 1


Download Now

Share on Social Media

           

PowerPoint is the world's most popular presentation software which can let you create professional Allergy and Asthma-Improving Outcomes in Primary Care powerpoint presentation easily and in no time. This helps you give your presentation on Allergy and Asthma-Improving Outcomes in Primary Care in a conference, a school lecture, a business proposal, in a webinar and business and professional representations.

The uploader spent his/her valuable time to create this Allergy and Asthma-Improving Outcomes in Primary Care powerpoint presentation slides, to share his/her useful content with the world. This ppt presentation uploaded by slidesfinder in Health & Wellness ppt presentation category is available for free download,and can be used according to your industries like finance, marketing, education, health and many more.

SlidesFinder.com provides a platform to marketers, presenters and educationists along with being the preferred search engine for professional PowerPoint presentations on the Internet to upload their Allergy and Asthma-Improving Outcomes in Primary Care ppt presentation slides to help them BUILD THEIR CROWD!!

Slide 1 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP
Slide 2 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management
Slide 3 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response
Slide 4 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs
Slide 5 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs
Slide 6 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs
Slide 7 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs
Slide 8 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs
Slide 9 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs
Slide 10 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs
Slide 11 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs
Slide 12 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs
Slide 13 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs
Slide 14 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs
Slide 15 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs
Slide 16 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees
Slide 17 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients
Slide 18 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs
Slide 19 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology
Slide 20 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs
Slide 21 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide
Slide 22 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs
Slide 23 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs
Slide 24 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs
Slide 25 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs
Slide 26 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031.
Slide 27 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral?
Slide 28 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs
Slide 29 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412.
Slide 30 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs
Slide 31 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs
Slide 32 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs
Slide 33 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs
Slide 34 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs
Slide 35 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs
Slide 36 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs
Slide 37 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives
Slide 38 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs
Slide 39 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response
Slide 40 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs
Slide 41 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide
Slide 42 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide What Is Happening to Treatment? Mechanism of disease is better understood Means that treatments are nearer the root cause Therapeutic specificity is increasing Diseases are different and differentiation is key The mechanism of action of drugs is more specific than ever Diagnostic precision by PCP is necessary New diagnostic technology must be employed Treatment Treatment
Slide 43 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide What Is Happening to Treatment? Mechanism of disease is better understood Means that treatments are nearer the root cause Therapeutic specificity is increasing Diseases are different and differentiation is key The mechanism of action of drugs is more specific than ever Diagnostic precision by PCP is necessary New diagnostic technology must be employed Treatment Treatment Treatment Market Review: The Role of Diagnostics in Pharmacotherapy Medications for Respiratory Allergy $$$$$$ Highly specific treatment Highly specific resolution of symptoms due to IgE response only — necessitates perfect diagnosis Binds to IgE; Suppression of IgE response Anti-IgE Vaccine (2003) $$$ Very specific to atopy — necessitates even more accurate diagnosis (Doctors report marginal response for AR with Singulair — could be 65% are not allergic) Specific resolution of symptoms of atopy by blocking another mediator pathway Leukotriene antagonist Montelukast (2002) $$ Introduction of “D” formula creates less specific treatment More specific resolution of symptoms primarily due to atopic etiology — necessitates more specific diagnosis Antihistamine effect with very little anticholinergic effect Non-sedating Antihistamines (1990s) $ Broad (shotgun) Non-specific resolution of symptoms regardless of etiology Antihistamine effect + Anticholinergic effect 1st Generation Antihistamines (1970s) Cost Therapeutic Approach Treatment Results Mode(s) of Action Treatment Progression Treatment Treatment
Slide 44 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide What Is Happening to Treatment? Mechanism of disease is better understood Means that treatments are nearer the root cause Therapeutic specificity is increasing Diseases are different and differentiation is key The mechanism of action of drugs is more specific than ever Diagnostic precision by PCP is necessary New diagnostic technology must be employed Treatment Treatment Treatment Market Review: The Role of Diagnostics in Pharmacotherapy Medications for Respiratory Allergy $$$$$$ Highly specific treatment Highly specific resolution of symptoms due to IgE response only — necessitates perfect diagnosis Binds to IgE; Suppression of IgE response Anti-IgE Vaccine (2003) $$$ Very specific to atopy — necessitates even more accurate diagnosis (Doctors report marginal response for AR with Singulair — could be 65% are not allergic) Specific resolution of symptoms of atopy by blocking another mediator pathway Leukotriene antagonist Montelukast (2002) $$ Introduction of “D” formula creates less specific treatment More specific resolution of symptoms primarily due to atopic etiology — necessitates more specific diagnosis Antihistamine effect with very little anticholinergic effect Non-sedating Antihistamines (1990s) $ Broad (shotgun) Non-specific resolution of symptoms regardless of etiology Antihistamine effect + Anticholinergic effect 1st Generation Antihistamines (1970s) Cost Therapeutic Approach Treatment Results Mode(s) of Action Treatment Progression Treatment Treatment Disease Paradigms Treatment Treatment Hx & PE lab tests diet & exercise pharmacotherapy Diabetes Mellitus Type 2 Hx & PE lipid profile diet & exercise pharmacotherapy Hypercholesterolemia Hx & PE pharmacotherapy CHDs, URDs, LRDs ? IgE profile avoidance
Slide 45 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide What Is Happening to Treatment? Mechanism of disease is better understood Means that treatments are nearer the root cause Therapeutic specificity is increasing Diseases are different and differentiation is key The mechanism of action of drugs is more specific than ever Diagnostic precision by PCP is necessary New diagnostic technology must be employed Treatment Treatment Treatment Market Review: The Role of Diagnostics in Pharmacotherapy Medications for Respiratory Allergy $$$$$$ Highly specific treatment Highly specific resolution of symptoms due to IgE response only — necessitates perfect diagnosis Binds to IgE; Suppression of IgE response Anti-IgE Vaccine (2003) $$$ Very specific to atopy — necessitates even more accurate diagnosis (Doctors report marginal response for AR with Singulair — could be 65% are not allergic) Specific resolution of symptoms of atopy by blocking another mediator pathway Leukotriene antagonist Montelukast (2002) $$ Introduction of “D” formula creates less specific treatment More specific resolution of symptoms primarily due to atopic etiology — necessitates more specific diagnosis Antihistamine effect with very little anticholinergic effect Non-sedating Antihistamines (1990s) $ Broad (shotgun) Non-specific resolution of symptoms regardless of etiology Antihistamine effect + Anticholinergic effect 1st Generation Antihistamines (1970s) Cost Therapeutic Approach Treatment Results Mode(s) of Action Treatment Progression Treatment Treatment Disease Paradigms Treatment Treatment Hx & PE lab tests diet & exercise pharmacotherapy Diabetes Mellitus Type 2 Hx & PE lipid profile diet & exercise pharmacotherapy Hypercholesterolemia Hx & PE pharmacotherapy CHDs, URDs, LRDs ? IgE profile avoidance CAP RAST: Gain Knowledge to Guide Treatment FDA-cleared quantitative measure of specific IgE Only a single blood draw required Covered under most insurance plans Accuracy superior to RASTTM*1 Next-generation assay offers consistently improved sensitivity,2 De facto standard, documented in >2,700 peer-reviewed publications3 In vitro blood testing and skin prick testing (SPT) viewed as interchangeable4 CAP RAST is available throughout the nation from all major reference and clinical laboratories, including Quest Diagnostics, NS-LIJ & BioReference * RAST is a trademark of Pharmacia Diagnostics. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. Szeinbach SL, et al. Ann Allergy Asthma Immunol. 2001;86:373-381. 3. Johansson SGO. Expert Rev Mol Diagn. 2004;4:273-279. 4. Hamilton RG. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:233-242. CAP RAST® CAP RAST®
Slide 46 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide What Is Happening to Treatment? Mechanism of disease is better understood Means that treatments are nearer the root cause Therapeutic specificity is increasing Diseases are different and differentiation is key The mechanism of action of drugs is more specific than ever Diagnostic precision by PCP is necessary New diagnostic technology must be employed Treatment Treatment Treatment Market Review: The Role of Diagnostics in Pharmacotherapy Medications for Respiratory Allergy $$$$$$ Highly specific treatment Highly specific resolution of symptoms due to IgE response only — necessitates perfect diagnosis Binds to IgE; Suppression of IgE response Anti-IgE Vaccine (2003) $$$ Very specific to atopy — necessitates even more accurate diagnosis (Doctors report marginal response for AR with Singulair — could be 65% are not allergic) Specific resolution of symptoms of atopy by blocking another mediator pathway Leukotriene antagonist Montelukast (2002) $$ Introduction of “D” formula creates less specific treatment More specific resolution of symptoms primarily due to atopic etiology — necessitates more specific diagnosis Antihistamine effect with very little anticholinergic effect Non-sedating Antihistamines (1990s) $ Broad (shotgun) Non-specific resolution of symptoms regardless of etiology Antihistamine effect + Anticholinergic effect 1st Generation Antihistamines (1970s) Cost Therapeutic Approach Treatment Results Mode(s) of Action Treatment Progression Treatment Treatment Disease Paradigms Treatment Treatment Hx & PE lab tests diet & exercise pharmacotherapy Diabetes Mellitus Type 2 Hx & PE lipid profile diet & exercise pharmacotherapy Hypercholesterolemia Hx & PE pharmacotherapy CHDs, URDs, LRDs ? IgE profile avoidance CAP RAST: Gain Knowledge to Guide Treatment FDA-cleared quantitative measure of specific IgE Only a single blood draw required Covered under most insurance plans Accuracy superior to RASTTM*1 Next-generation assay offers consistently improved sensitivity,2 De facto standard, documented in >2,700 peer-reviewed publications3 In vitro blood testing and skin prick testing (SPT) viewed as interchangeable4 CAP RAST is available throughout the nation from all major reference and clinical laboratories, including Quest Diagnostics, NS-LIJ & BioReference * RAST is a trademark of Pharmacia Diagnostics. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. Szeinbach SL, et al. Ann Allergy Asthma Immunol. 2001;86:373-381. 3. Johansson SGO. Expert Rev Mol Diagn. 2004;4:273-279. 4. Hamilton RG. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:233-242. CAP RAST® CAP RAST® H. Drevin, 1989 A. Kober, 2004 Solid-phase Protein Binding Capacity Comparison Solid Phase CAP RAST cellulose polymer binds almost 150 times more protein than a passively coated tube, well or bead, and about 250 percent more protein than a paper disc.
Slide 47 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide What Is Happening to Treatment? Mechanism of disease is better understood Means that treatments are nearer the root cause Therapeutic specificity is increasing Diseases are different and differentiation is key The mechanism of action of drugs is more specific than ever Diagnostic precision by PCP is necessary New diagnostic technology must be employed Treatment Treatment Treatment Market Review: The Role of Diagnostics in Pharmacotherapy Medications for Respiratory Allergy $$$$$$ Highly specific treatment Highly specific resolution of symptoms due to IgE response only — necessitates perfect diagnosis Binds to IgE; Suppression of IgE response Anti-IgE Vaccine (2003) $$$ Very specific to atopy — necessitates even more accurate diagnosis (Doctors report marginal response for AR with Singulair — could be 65% are not allergic) Specific resolution of symptoms of atopy by blocking another mediator pathway Leukotriene antagonist Montelukast (2002) $$ Introduction of “D” formula creates less specific treatment More specific resolution of symptoms primarily due to atopic etiology — necessitates more specific diagnosis Antihistamine effect with very little anticholinergic effect Non-sedating Antihistamines (1990s) $ Broad (shotgun) Non-specific resolution of symptoms regardless of etiology Antihistamine effect + Anticholinergic effect 1st Generation Antihistamines (1970s) Cost Therapeutic Approach Treatment Results Mode(s) of Action Treatment Progression Treatment Treatment Disease Paradigms Treatment Treatment Hx & PE lab tests diet & exercise pharmacotherapy Diabetes Mellitus Type 2 Hx & PE lipid profile diet & exercise pharmacotherapy Hypercholesterolemia Hx & PE pharmacotherapy CHDs, URDs, LRDs ? IgE profile avoidance CAP RAST: Gain Knowledge to Guide Treatment FDA-cleared quantitative measure of specific IgE Only a single blood draw required Covered under most insurance plans Accuracy superior to RASTTM*1 Next-generation assay offers consistently improved sensitivity,2 De facto standard, documented in >2,700 peer-reviewed publications3 In vitro blood testing and skin prick testing (SPT) viewed as interchangeable4 CAP RAST is available throughout the nation from all major reference and clinical laboratories, including Quest Diagnostics, NS-LIJ & BioReference * RAST is a trademark of Pharmacia Diagnostics. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. Szeinbach SL, et al. Ann Allergy Asthma Immunol. 2001;86:373-381. 3. Johansson SGO. Expert Rev Mol Diagn. 2004;4:273-279. 4. Hamilton RG. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:233-242. CAP RAST® CAP RAST® H. Drevin, 1989 A. Kober, 2004 Solid-phase Protein Binding Capacity Comparison Solid Phase CAP RAST cellulose polymer binds almost 150 times more protein than a passively coated tube, well or bead, and about 250 percent more protein than a paper disc. Accuracy of Immunoassays for Specific IgE *The authors noted that regression values below 0.80 reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. ONLY CAP RAST had consistently acceptable regression values. **Alastat was recently replaced by 3gAllergy. Studies show 93% agreement between both methods. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. CAP RAST® CAP RAST® Line represents minimum acceptable R2 performance values Alastat/ 3gAllergyTM** RAST/ Modified RAST Newest generation: CAP RAST Ideal Test (Correlation Coefficient) .65 .82 .96 - .98 1.0
Slide 48 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide What Is Happening to Treatment? Mechanism of disease is better understood Means that treatments are nearer the root cause Therapeutic specificity is increasing Diseases are different and differentiation is key The mechanism of action of drugs is more specific than ever Diagnostic precision by PCP is necessary New diagnostic technology must be employed Treatment Treatment Treatment Market Review: The Role of Diagnostics in Pharmacotherapy Medications for Respiratory Allergy $$$$$$ Highly specific treatment Highly specific resolution of symptoms due to IgE response only — necessitates perfect diagnosis Binds to IgE; Suppression of IgE response Anti-IgE Vaccine (2003) $$$ Very specific to atopy — necessitates even more accurate diagnosis (Doctors report marginal response for AR with Singulair — could be 65% are not allergic) Specific resolution of symptoms of atopy by blocking another mediator pathway Leukotriene antagonist Montelukast (2002) $$ Introduction of “D” formula creates less specific treatment More specific resolution of symptoms primarily due to atopic etiology — necessitates more specific diagnosis Antihistamine effect with very little anticholinergic effect Non-sedating Antihistamines (1990s) $ Broad (shotgun) Non-specific resolution of symptoms regardless of etiology Antihistamine effect + Anticholinergic effect 1st Generation Antihistamines (1970s) Cost Therapeutic Approach Treatment Results Mode(s) of Action Treatment Progression Treatment Treatment Disease Paradigms Treatment Treatment Hx & PE lab tests diet & exercise pharmacotherapy Diabetes Mellitus Type 2 Hx & PE lipid profile diet & exercise pharmacotherapy Hypercholesterolemia Hx & PE pharmacotherapy CHDs, URDs, LRDs ? IgE profile avoidance CAP RAST: Gain Knowledge to Guide Treatment FDA-cleared quantitative measure of specific IgE Only a single blood draw required Covered under most insurance plans Accuracy superior to RASTTM*1 Next-generation assay offers consistently improved sensitivity,2 De facto standard, documented in >2,700 peer-reviewed publications3 In vitro blood testing and skin prick testing (SPT) viewed as interchangeable4 CAP RAST is available throughout the nation from all major reference and clinical laboratories, including Quest Diagnostics, NS-LIJ & BioReference * RAST is a trademark of Pharmacia Diagnostics. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. Szeinbach SL, et al. Ann Allergy Asthma Immunol. 2001;86:373-381. 3. Johansson SGO. Expert Rev Mol Diagn. 2004;4:273-279. 4. Hamilton RG. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:233-242. CAP RAST® CAP RAST® H. Drevin, 1989 A. Kober, 2004 Solid-phase Protein Binding Capacity Comparison Solid Phase CAP RAST cellulose polymer binds almost 150 times more protein than a passively coated tube, well or bead, and about 250 percent more protein than a paper disc. Accuracy of Immunoassays for Specific IgE *The authors noted that regression values below 0.80 reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. ONLY CAP RAST had consistently acceptable regression values. **Alastat was recently replaced by 3gAllergy. Studies show 93% agreement between both methods. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. CAP RAST® CAP RAST® Line represents minimum acceptable R2 performance values Alastat/ 3gAllergyTM** RAST/ Modified RAST Newest generation: CAP RAST Ideal Test (Correlation Coefficient) .65 .82 .96 - .98 1.0 Source: Williams PB, Barnes JH, Szeinbach SL, Sullivan T. Analytical precision and accuracy of commercial immunoassays for specific IgE: establishing a standard. J Allergy Clin Immunol. 2000;105(6):1221-1230. Poor Performance For Tests With R2 Below 0.80 “Given the dilution range used in this study, values of R-Square below approximately 0.80 generally reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. Only CAP RAST had consistently acceptable R-Square values, suggesting good performance in their ability to correctly detect the concentrations of specific IgE antibodies across the different samples and allergens.”
Slide 49 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide What Is Happening to Treatment? Mechanism of disease is better understood Means that treatments are nearer the root cause Therapeutic specificity is increasing Diseases are different and differentiation is key The mechanism of action of drugs is more specific than ever Diagnostic precision by PCP is necessary New diagnostic technology must be employed Treatment Treatment Treatment Market Review: The Role of Diagnostics in Pharmacotherapy Medications for Respiratory Allergy $$$$$$ Highly specific treatment Highly specific resolution of symptoms due to IgE response only — necessitates perfect diagnosis Binds to IgE; Suppression of IgE response Anti-IgE Vaccine (2003) $$$ Very specific to atopy — necessitates even more accurate diagnosis (Doctors report marginal response for AR with Singulair — could be 65% are not allergic) Specific resolution of symptoms of atopy by blocking another mediator pathway Leukotriene antagonist Montelukast (2002) $$ Introduction of “D” formula creates less specific treatment More specific resolution of symptoms primarily due to atopic etiology — necessitates more specific diagnosis Antihistamine effect with very little anticholinergic effect Non-sedating Antihistamines (1990s) $ Broad (shotgun) Non-specific resolution of symptoms regardless of etiology Antihistamine effect + Anticholinergic effect 1st Generation Antihistamines (1970s) Cost Therapeutic Approach Treatment Results Mode(s) of Action Treatment Progression Treatment Treatment Disease Paradigms Treatment Treatment Hx & PE lab tests diet & exercise pharmacotherapy Diabetes Mellitus Type 2 Hx & PE lipid profile diet & exercise pharmacotherapy Hypercholesterolemia Hx & PE pharmacotherapy CHDs, URDs, LRDs ? IgE profile avoidance CAP RAST: Gain Knowledge to Guide Treatment FDA-cleared quantitative measure of specific IgE Only a single blood draw required Covered under most insurance plans Accuracy superior to RASTTM*1 Next-generation assay offers consistently improved sensitivity,2 De facto standard, documented in >2,700 peer-reviewed publications3 In vitro blood testing and skin prick testing (SPT) viewed as interchangeable4 CAP RAST is available throughout the nation from all major reference and clinical laboratories, including Quest Diagnostics, NS-LIJ & BioReference * RAST is a trademark of Pharmacia Diagnostics. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. Szeinbach SL, et al. Ann Allergy Asthma Immunol. 2001;86:373-381. 3. Johansson SGO. Expert Rev Mol Diagn. 2004;4:273-279. 4. Hamilton RG. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:233-242. CAP RAST® CAP RAST® H. Drevin, 1989 A. Kober, 2004 Solid-phase Protein Binding Capacity Comparison Solid Phase CAP RAST cellulose polymer binds almost 150 times more protein than a passively coated tube, well or bead, and about 250 percent more protein than a paper disc. Accuracy of Immunoassays for Specific IgE *The authors noted that regression values below 0.80 reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. ONLY CAP RAST had consistently acceptable regression values. **Alastat was recently replaced by 3gAllergy. Studies show 93% agreement between both methods. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. CAP RAST® CAP RAST® Line represents minimum acceptable R2 performance values Alastat/ 3gAllergyTM** RAST/ Modified RAST Newest generation: CAP RAST Ideal Test (Correlation Coefficient) .65 .82 .96 - .98 1.0 Source: Williams PB, Barnes JH, Szeinbach SL, Sullivan T. Analytical precision and accuracy of commercial immunoassays for specific IgE: establishing a standard. J Allergy Clin Immunol. 2000;105(6):1221-1230. Poor Performance For Tests With R2 Below 0.80 “Given the dilution range used in this study, values of R-Square below approximately 0.80 generally reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. Only CAP RAST had consistently acceptable R-Square values, suggesting good performance in their ability to correctly detect the concentrations of specific IgE antibodies across the different samples and allergens.” Predictive Value vs. Skin Prick Testing (SPT)* *Adapted from Reference 1. †CAP RAST Specific IgE blood test was used in this study. 1. Wood RA, et al. J Allergy Clin Immunol. 1999;103:733-779. CAP RAST Authors concluded that CAP RAST Specific IgE blood test and SPT values both exhibited excellent efficiency1 CAP RAST® Return to previous slide
Slide 50 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide What Is Happening to Treatment? Mechanism of disease is better understood Means that treatments are nearer the root cause Therapeutic specificity is increasing Diseases are different and differentiation is key The mechanism of action of drugs is more specific than ever Diagnostic precision by PCP is necessary New diagnostic technology must be employed Treatment Treatment Treatment Market Review: The Role of Diagnostics in Pharmacotherapy Medications for Respiratory Allergy $$$$$$ Highly specific treatment Highly specific resolution of symptoms due to IgE response only — necessitates perfect diagnosis Binds to IgE; Suppression of IgE response Anti-IgE Vaccine (2003) $$$ Very specific to atopy — necessitates even more accurate diagnosis (Doctors report marginal response for AR with Singulair — could be 65% are not allergic) Specific resolution of symptoms of atopy by blocking another mediator pathway Leukotriene antagonist Montelukast (2002) $$ Introduction of “D” formula creates less specific treatment More specific resolution of symptoms primarily due to atopic etiology — necessitates more specific diagnosis Antihistamine effect with very little anticholinergic effect Non-sedating Antihistamines (1990s) $ Broad (shotgun) Non-specific resolution of symptoms regardless of etiology Antihistamine effect + Anticholinergic effect 1st Generation Antihistamines (1970s) Cost Therapeutic Approach Treatment Results Mode(s) of Action Treatment Progression Treatment Treatment Disease Paradigms Treatment Treatment Hx & PE lab tests diet & exercise pharmacotherapy Diabetes Mellitus Type 2 Hx & PE lipid profile diet & exercise pharmacotherapy Hypercholesterolemia Hx & PE pharmacotherapy CHDs, URDs, LRDs ? IgE profile avoidance CAP RAST: Gain Knowledge to Guide Treatment FDA-cleared quantitative measure of specific IgE Only a single blood draw required Covered under most insurance plans Accuracy superior to RASTTM*1 Next-generation assay offers consistently improved sensitivity,2 De facto standard, documented in >2,700 peer-reviewed publications3 In vitro blood testing and skin prick testing (SPT) viewed as interchangeable4 CAP RAST is available throughout the nation from all major reference and clinical laboratories, including Quest Diagnostics, NS-LIJ & BioReference * RAST is a trademark of Pharmacia Diagnostics. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. Szeinbach SL, et al. Ann Allergy Asthma Immunol. 2001;86:373-381. 3. Johansson SGO. Expert Rev Mol Diagn. 2004;4:273-279. 4. Hamilton RG. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:233-242. CAP RAST® CAP RAST® H. Drevin, 1989 A. Kober, 2004 Solid-phase Protein Binding Capacity Comparison Solid Phase CAP RAST cellulose polymer binds almost 150 times more protein than a passively coated tube, well or bead, and about 250 percent more protein than a paper disc. Accuracy of Immunoassays for Specific IgE *The authors noted that regression values below 0.80 reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. ONLY CAP RAST had consistently acceptable regression values. **Alastat was recently replaced by 3gAllergy. Studies show 93% agreement between both methods. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. CAP RAST® CAP RAST® Line represents minimum acceptable R2 performance values Alastat/ 3gAllergyTM** RAST/ Modified RAST Newest generation: CAP RAST Ideal Test (Correlation Coefficient) .65 .82 .96 - .98 1.0 Source: Williams PB, Barnes JH, Szeinbach SL, Sullivan T. Analytical precision and accuracy of commercial immunoassays for specific IgE: establishing a standard. J Allergy Clin Immunol. 2000;105(6):1221-1230. Poor Performance For Tests With R2 Below 0.80 “Given the dilution range used in this study, values of R-Square below approximately 0.80 generally reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. Only CAP RAST had consistently acceptable R-Square values, suggesting good performance in their ability to correctly detect the concentrations of specific IgE antibodies across the different samples and allergens.” Predictive Value vs. Skin Prick Testing (SPT)* *Adapted from Reference 1. †CAP RAST Specific IgE blood test was used in this study. 1. Wood RA, et al. J Allergy Clin Immunol. 1999;103:733-779. CAP RAST Authors concluded that CAP RAST Specific IgE blood test and SPT values both exhibited excellent efficiency1 CAP RAST® Return to previous slide Profiles Carefully Designed Profiles engineered to detect >95% of patients with allergy1-3 Regional respiratory profiles include key indoor/outdoor allergens selected according to: Geographic pollen patterns Regional disease prevalence Cross reactivity to other allergens in each inhalant class Allergy March profiles include key food/inhalant allergens Six foods account for 90% of food allergy reactions in children4 Inhalants include common/cross-reactive indoor and outdoor allergens Generally recommended for children ≤6 years of age, based on symptoms CAP RAST Sampson HA, Ho DG. J Allergy Clin Immunol. 1997;100:444-451. Yunginger JW, et al. J Allergy Clin Immunol. 2000;105:1077-1084. Poon AW, et al. Am J Man Care. 1998;4:969-985. AAAAI. The Allergy Report. 2000;3:69. CAP RAST®
Slide 51 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide What Is Happening to Treatment? Mechanism of disease is better understood Means that treatments are nearer the root cause Therapeutic specificity is increasing Diseases are different and differentiation is key The mechanism of action of drugs is more specific than ever Diagnostic precision by PCP is necessary New diagnostic technology must be employed Treatment Treatment Treatment Market Review: The Role of Diagnostics in Pharmacotherapy Medications for Respiratory Allergy $$$$$$ Highly specific treatment Highly specific resolution of symptoms due to IgE response only — necessitates perfect diagnosis Binds to IgE; Suppression of IgE response Anti-IgE Vaccine (2003) $$$ Very specific to atopy — necessitates even more accurate diagnosis (Doctors report marginal response for AR with Singulair — could be 65% are not allergic) Specific resolution of symptoms of atopy by blocking another mediator pathway Leukotriene antagonist Montelukast (2002) $$ Introduction of “D” formula creates less specific treatment More specific resolution of symptoms primarily due to atopic etiology — necessitates more specific diagnosis Antihistamine effect with very little anticholinergic effect Non-sedating Antihistamines (1990s) $ Broad (shotgun) Non-specific resolution of symptoms regardless of etiology Antihistamine effect + Anticholinergic effect 1st Generation Antihistamines (1970s) Cost Therapeutic Approach Treatment Results Mode(s) of Action Treatment Progression Treatment Treatment Disease Paradigms Treatment Treatment Hx & PE lab tests diet & exercise pharmacotherapy Diabetes Mellitus Type 2 Hx & PE lipid profile diet & exercise pharmacotherapy Hypercholesterolemia Hx & PE pharmacotherapy CHDs, URDs, LRDs ? IgE profile avoidance CAP RAST: Gain Knowledge to Guide Treatment FDA-cleared quantitative measure of specific IgE Only a single blood draw required Covered under most insurance plans Accuracy superior to RASTTM*1 Next-generation assay offers consistently improved sensitivity,2 De facto standard, documented in >2,700 peer-reviewed publications3 In vitro blood testing and skin prick testing (SPT) viewed as interchangeable4 CAP RAST is available throughout the nation from all major reference and clinical laboratories, including Quest Diagnostics, NS-LIJ & BioReference * RAST is a trademark of Pharmacia Diagnostics. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. Szeinbach SL, et al. Ann Allergy Asthma Immunol. 2001;86:373-381. 3. Johansson SGO. Expert Rev Mol Diagn. 2004;4:273-279. 4. Hamilton RG. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:233-242. CAP RAST® CAP RAST® H. Drevin, 1989 A. Kober, 2004 Solid-phase Protein Binding Capacity Comparison Solid Phase CAP RAST cellulose polymer binds almost 150 times more protein than a passively coated tube, well or bead, and about 250 percent more protein than a paper disc. Accuracy of Immunoassays for Specific IgE *The authors noted that regression values below 0.80 reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. ONLY CAP RAST had consistently acceptable regression values. **Alastat was recently replaced by 3gAllergy. Studies show 93% agreement between both methods. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. CAP RAST® CAP RAST® Line represents minimum acceptable R2 performance values Alastat/ 3gAllergyTM** RAST/ Modified RAST Newest generation: CAP RAST Ideal Test (Correlation Coefficient) .65 .82 .96 - .98 1.0 Source: Williams PB, Barnes JH, Szeinbach SL, Sullivan T. Analytical precision and accuracy of commercial immunoassays for specific IgE: establishing a standard. J Allergy Clin Immunol. 2000;105(6):1221-1230. Poor Performance For Tests With R2 Below 0.80 “Given the dilution range used in this study, values of R-Square below approximately 0.80 generally reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. Only CAP RAST had consistently acceptable R-Square values, suggesting good performance in their ability to correctly detect the concentrations of specific IgE antibodies across the different samples and allergens.” Predictive Value vs. Skin Prick Testing (SPT)* *Adapted from Reference 1. †CAP RAST Specific IgE blood test was used in this study. 1. Wood RA, et al. J Allergy Clin Immunol. 1999;103:733-779. CAP RAST Authors concluded that CAP RAST Specific IgE blood test and SPT values both exhibited excellent efficiency1 CAP RAST® Return to previous slide Profiles Carefully Designed Profiles engineered to detect >95% of patients with allergy1-3 Regional respiratory profiles include key indoor/outdoor allergens selected according to: Geographic pollen patterns Regional disease prevalence Cross reactivity to other allergens in each inhalant class Allergy March profiles include key food/inhalant allergens Six foods account for 90% of food allergy reactions in children4 Inhalants include common/cross-reactive indoor and outdoor allergens Generally recommended for children ≤6 years of age, based on symptoms CAP RAST Sampson HA, Ho DG. J Allergy Clin Immunol. 1997;100:444-451. Yunginger JW, et al. J Allergy Clin Immunol. 2000;105:1077-1084. Poon AW, et al. Am J Man Care. 1998;4:969-985. AAAAI. The Allergy Report. 2000;3:69. CAP RAST® Understanding Total IgE1 Total IgE often of little practical value when considered alone Levels rarely high when specific IgE titers are not Lacks sensitivity as a rule-out screen: Specific IgE levels may be significantly high when total IgE is low/normal Extremely high total IgE may be seen in some very rare non-atopic conditions2: Certain immunodeficiency diseases (including HIV) IgE myeloma Drug-induced interstitial nephritis Graft-versus-host disease Parasitic diseases Skin diseases in addition to eczema Hyper-IgE syndrome (dermatitis, recurrent pyogenic infection) CAP RAST Fromer LM. J Fam Pract. 2004;suppl:S4-S14. AAAAI. The Allergy Report. 2000;1:35. CAP RAST®
Slide 52 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide What Is Happening to Treatment? Mechanism of disease is better understood Means that treatments are nearer the root cause Therapeutic specificity is increasing Diseases are different and differentiation is key The mechanism of action of drugs is more specific than ever Diagnostic precision by PCP is necessary New diagnostic technology must be employed Treatment Treatment Treatment Market Review: The Role of Diagnostics in Pharmacotherapy Medications for Respiratory Allergy $$$$$$ Highly specific treatment Highly specific resolution of symptoms due to IgE response only — necessitates perfect diagnosis Binds to IgE; Suppression of IgE response Anti-IgE Vaccine (2003) $$$ Very specific to atopy — necessitates even more accurate diagnosis (Doctors report marginal response for AR with Singulair — could be 65% are not allergic) Specific resolution of symptoms of atopy by blocking another mediator pathway Leukotriene antagonist Montelukast (2002) $$ Introduction of “D” formula creates less specific treatment More specific resolution of symptoms primarily due to atopic etiology — necessitates more specific diagnosis Antihistamine effect with very little anticholinergic effect Non-sedating Antihistamines (1990s) $ Broad (shotgun) Non-specific resolution of symptoms regardless of etiology Antihistamine effect + Anticholinergic effect 1st Generation Antihistamines (1970s) Cost Therapeutic Approach Treatment Results Mode(s) of Action Treatment Progression Treatment Treatment Disease Paradigms Treatment Treatment Hx & PE lab tests diet & exercise pharmacotherapy Diabetes Mellitus Type 2 Hx & PE lipid profile diet & exercise pharmacotherapy Hypercholesterolemia Hx & PE pharmacotherapy CHDs, URDs, LRDs ? IgE profile avoidance CAP RAST: Gain Knowledge to Guide Treatment FDA-cleared quantitative measure of specific IgE Only a single blood draw required Covered under most insurance plans Accuracy superior to RASTTM*1 Next-generation assay offers consistently improved sensitivity,2 De facto standard, documented in >2,700 peer-reviewed publications3 In vitro blood testing and skin prick testing (SPT) viewed as interchangeable4 CAP RAST is available throughout the nation from all major reference and clinical laboratories, including Quest Diagnostics, NS-LIJ & BioReference * RAST is a trademark of Pharmacia Diagnostics. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. Szeinbach SL, et al. Ann Allergy Asthma Immunol. 2001;86:373-381. 3. Johansson SGO. Expert Rev Mol Diagn. 2004;4:273-279. 4. Hamilton RG. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:233-242. CAP RAST® CAP RAST® H. Drevin, 1989 A. Kober, 2004 Solid-phase Protein Binding Capacity Comparison Solid Phase CAP RAST cellulose polymer binds almost 150 times more protein than a passively coated tube, well or bead, and about 250 percent more protein than a paper disc. Accuracy of Immunoassays for Specific IgE *The authors noted that regression values below 0.80 reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. ONLY CAP RAST had consistently acceptable regression values. **Alastat was recently replaced by 3gAllergy. Studies show 93% agreement between both methods. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. CAP RAST® CAP RAST® Line represents minimum acceptable R2 performance values Alastat/ 3gAllergyTM** RAST/ Modified RAST Newest generation: CAP RAST Ideal Test (Correlation Coefficient) .65 .82 .96 - .98 1.0 Source: Williams PB, Barnes JH, Szeinbach SL, Sullivan T. Analytical precision and accuracy of commercial immunoassays for specific IgE: establishing a standard. J Allergy Clin Immunol. 2000;105(6):1221-1230. Poor Performance For Tests With R2 Below 0.80 “Given the dilution range used in this study, values of R-Square below approximately 0.80 generally reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. Only CAP RAST had consistently acceptable R-Square values, suggesting good performance in their ability to correctly detect the concentrations of specific IgE antibodies across the different samples and allergens.” Predictive Value vs. Skin Prick Testing (SPT)* *Adapted from Reference 1. †CAP RAST Specific IgE blood test was used in this study. 1. Wood RA, et al. J Allergy Clin Immunol. 1999;103:733-779. CAP RAST Authors concluded that CAP RAST Specific IgE blood test and SPT values both exhibited excellent efficiency1 CAP RAST® Return to previous slide Profiles Carefully Designed Profiles engineered to detect >95% of patients with allergy1-3 Regional respiratory profiles include key indoor/outdoor allergens selected according to: Geographic pollen patterns Regional disease prevalence Cross reactivity to other allergens in each inhalant class Allergy March profiles include key food/inhalant allergens Six foods account for 90% of food allergy reactions in children4 Inhalants include common/cross-reactive indoor and outdoor allergens Generally recommended for children ≤6 years of age, based on symptoms CAP RAST Sampson HA, Ho DG. J Allergy Clin Immunol. 1997;100:444-451. Yunginger JW, et al. J Allergy Clin Immunol. 2000;105:1077-1084. Poon AW, et al. Am J Man Care. 1998;4:969-985. AAAAI. The Allergy Report. 2000;3:69. CAP RAST® Understanding Total IgE1 Total IgE often of little practical value when considered alone Levels rarely high when specific IgE titers are not Lacks sensitivity as a rule-out screen: Specific IgE levels may be significantly high when total IgE is low/normal Extremely high total IgE may be seen in some very rare non-atopic conditions2: Certain immunodeficiency diseases (including HIV) IgE myeloma Drug-induced interstitial nephritis Graft-versus-host disease Parasitic diseases Skin diseases in addition to eczema Hyper-IgE syndrome (dermatitis, recurrent pyogenic infection) CAP RAST Fromer LM. J Fam Pract. 2004;suppl:S4-S14. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Understanding Total IgE CAP RAST Return to previous slide *Includes URDs (Upper Respiratory Diseases), CHDs (Childhood Diseases), and LRDs (Lower Respiratory Diseases) 1. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Interpretation of Total IgE* Results Negative (Normal) Positive (Abnormal, Elevated) Negative (Normal) Positive (Abnormal, Elevated) Non-allergic Patient Scenario A Rare1 Scenario B Allergic Patient Scenario C Allergic Patient Scenario D Specific IgE Reading Total IgE Reading
Slide 53 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide What Is Happening to Treatment? Mechanism of disease is better understood Means that treatments are nearer the root cause Therapeutic specificity is increasing Diseases are different and differentiation is key The mechanism of action of drugs is more specific than ever Diagnostic precision by PCP is necessary New diagnostic technology must be employed Treatment Treatment Treatment Market Review: The Role of Diagnostics in Pharmacotherapy Medications for Respiratory Allergy $$$$$$ Highly specific treatment Highly specific resolution of symptoms due to IgE response only — necessitates perfect diagnosis Binds to IgE; Suppression of IgE response Anti-IgE Vaccine (2003) $$$ Very specific to atopy — necessitates even more accurate diagnosis (Doctors report marginal response for AR with Singulair — could be 65% are not allergic) Specific resolution of symptoms of atopy by blocking another mediator pathway Leukotriene antagonist Montelukast (2002) $$ Introduction of “D” formula creates less specific treatment More specific resolution of symptoms primarily due to atopic etiology — necessitates more specific diagnosis Antihistamine effect with very little anticholinergic effect Non-sedating Antihistamines (1990s) $ Broad (shotgun) Non-specific resolution of symptoms regardless of etiology Antihistamine effect + Anticholinergic effect 1st Generation Antihistamines (1970s) Cost Therapeutic Approach Treatment Results Mode(s) of Action Treatment Progression Treatment Treatment Disease Paradigms Treatment Treatment Hx & PE lab tests diet & exercise pharmacotherapy Diabetes Mellitus Type 2 Hx & PE lipid profile diet & exercise pharmacotherapy Hypercholesterolemia Hx & PE pharmacotherapy CHDs, URDs, LRDs ? IgE profile avoidance CAP RAST: Gain Knowledge to Guide Treatment FDA-cleared quantitative measure of specific IgE Only a single blood draw required Covered under most insurance plans Accuracy superior to RASTTM*1 Next-generation assay offers consistently improved sensitivity,2 De facto standard, documented in >2,700 peer-reviewed publications3 In vitro blood testing and skin prick testing (SPT) viewed as interchangeable4 CAP RAST is available throughout the nation from all major reference and clinical laboratories, including Quest Diagnostics, NS-LIJ & BioReference * RAST is a trademark of Pharmacia Diagnostics. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. Szeinbach SL, et al. Ann Allergy Asthma Immunol. 2001;86:373-381. 3. Johansson SGO. Expert Rev Mol Diagn. 2004;4:273-279. 4. Hamilton RG. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:233-242. CAP RAST® CAP RAST® H. Drevin, 1989 A. Kober, 2004 Solid-phase Protein Binding Capacity Comparison Solid Phase CAP RAST cellulose polymer binds almost 150 times more protein than a passively coated tube, well or bead, and about 250 percent more protein than a paper disc. Accuracy of Immunoassays for Specific IgE *The authors noted that regression values below 0.80 reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. ONLY CAP RAST had consistently acceptable regression values. **Alastat was recently replaced by 3gAllergy. Studies show 93% agreement between both methods. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. CAP RAST® CAP RAST® Line represents minimum acceptable R2 performance values Alastat/ 3gAllergyTM** RAST/ Modified RAST Newest generation: CAP RAST Ideal Test (Correlation Coefficient) .65 .82 .96 - .98 1.0 Source: Williams PB, Barnes JH, Szeinbach SL, Sullivan T. Analytical precision and accuracy of commercial immunoassays for specific IgE: establishing a standard. J Allergy Clin Immunol. 2000;105(6):1221-1230. Poor Performance For Tests With R2 Below 0.80 “Given the dilution range used in this study, values of R-Square below approximately 0.80 generally reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. Only CAP RAST had consistently acceptable R-Square values, suggesting good performance in their ability to correctly detect the concentrations of specific IgE antibodies across the different samples and allergens.” Predictive Value vs. Skin Prick Testing (SPT)* *Adapted from Reference 1. †CAP RAST Specific IgE blood test was used in this study. 1. Wood RA, et al. J Allergy Clin Immunol. 1999;103:733-779. CAP RAST Authors concluded that CAP RAST Specific IgE blood test and SPT values both exhibited excellent efficiency1 CAP RAST® Return to previous slide Profiles Carefully Designed Profiles engineered to detect >95% of patients with allergy1-3 Regional respiratory profiles include key indoor/outdoor allergens selected according to: Geographic pollen patterns Regional disease prevalence Cross reactivity to other allergens in each inhalant class Allergy March profiles include key food/inhalant allergens Six foods account for 90% of food allergy reactions in children4 Inhalants include common/cross-reactive indoor and outdoor allergens Generally recommended for children ≤6 years of age, based on symptoms CAP RAST Sampson HA, Ho DG. J Allergy Clin Immunol. 1997;100:444-451. Yunginger JW, et al. J Allergy Clin Immunol. 2000;105:1077-1084. Poon AW, et al. Am J Man Care. 1998;4:969-985. AAAAI. The Allergy Report. 2000;3:69. CAP RAST® Understanding Total IgE1 Total IgE often of little practical value when considered alone Levels rarely high when specific IgE titers are not Lacks sensitivity as a rule-out screen: Specific IgE levels may be significantly high when total IgE is low/normal Extremely high total IgE may be seen in some very rare non-atopic conditions2: Certain immunodeficiency diseases (including HIV) IgE myeloma Drug-induced interstitial nephritis Graft-versus-host disease Parasitic diseases Skin diseases in addition to eczema Hyper-IgE syndrome (dermatitis, recurrent pyogenic infection) CAP RAST Fromer LM. J Fam Pract. 2004;suppl:S4-S14. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Understanding Total IgE CAP RAST Return to previous slide *Includes URDs (Upper Respiratory Diseases), CHDs (Childhood Diseases), and LRDs (Lower Respiratory Diseases) 1. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Interpretation of Total IgE* Results Negative (Normal) Positive (Abnormal, Elevated) Negative (Normal) Positive (Abnormal, Elevated) Non-allergic Patient Scenario A Rare1 Scenario B Allergic Patient Scenario C Allergic Patient Scenario D Specific IgE Reading Total IgE Reading Perspectives Perspectives Third-party Perspectives Childhood diseases EAACI AAP Upper respiratory diseases JCAAI (guidelines for chronic rhinitis) AAAAI – The Allergy Report AHRQ (Agency for Healthcare Research and Quality) Multiple textbooks Lower respiratory diseases NIH (asthma guidelines) AAFP (asthma guidelines) FDA (Xolair® indications)
Slide 54 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide What Is Happening to Treatment? Mechanism of disease is better understood Means that treatments are nearer the root cause Therapeutic specificity is increasing Diseases are different and differentiation is key The mechanism of action of drugs is more specific than ever Diagnostic precision by PCP is necessary New diagnostic technology must be employed Treatment Treatment Treatment Market Review: The Role of Diagnostics in Pharmacotherapy Medications for Respiratory Allergy $$$$$$ Highly specific treatment Highly specific resolution of symptoms due to IgE response only — necessitates perfect diagnosis Binds to IgE; Suppression of IgE response Anti-IgE Vaccine (2003) $$$ Very specific to atopy — necessitates even more accurate diagnosis (Doctors report marginal response for AR with Singulair — could be 65% are not allergic) Specific resolution of symptoms of atopy by blocking another mediator pathway Leukotriene antagonist Montelukast (2002) $$ Introduction of “D” formula creates less specific treatment More specific resolution of symptoms primarily due to atopic etiology — necessitates more specific diagnosis Antihistamine effect with very little anticholinergic effect Non-sedating Antihistamines (1990s) $ Broad (shotgun) Non-specific resolution of symptoms regardless of etiology Antihistamine effect + Anticholinergic effect 1st Generation Antihistamines (1970s) Cost Therapeutic Approach Treatment Results Mode(s) of Action Treatment Progression Treatment Treatment Disease Paradigms Treatment Treatment Hx & PE lab tests diet & exercise pharmacotherapy Diabetes Mellitus Type 2 Hx & PE lipid profile diet & exercise pharmacotherapy Hypercholesterolemia Hx & PE pharmacotherapy CHDs, URDs, LRDs ? IgE profile avoidance CAP RAST: Gain Knowledge to Guide Treatment FDA-cleared quantitative measure of specific IgE Only a single blood draw required Covered under most insurance plans Accuracy superior to RASTTM*1 Next-generation assay offers consistently improved sensitivity,2 De facto standard, documented in >2,700 peer-reviewed publications3 In vitro blood testing and skin prick testing (SPT) viewed as interchangeable4 CAP RAST is available throughout the nation from all major reference and clinical laboratories, including Quest Diagnostics, NS-LIJ & BioReference * RAST is a trademark of Pharmacia Diagnostics. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. Szeinbach SL, et al. Ann Allergy Asthma Immunol. 2001;86:373-381. 3. Johansson SGO. Expert Rev Mol Diagn. 2004;4:273-279. 4. Hamilton RG. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:233-242. CAP RAST® CAP RAST® H. Drevin, 1989 A. Kober, 2004 Solid-phase Protein Binding Capacity Comparison Solid Phase CAP RAST cellulose polymer binds almost 150 times more protein than a passively coated tube, well or bead, and about 250 percent more protein than a paper disc. Accuracy of Immunoassays for Specific IgE *The authors noted that regression values below 0.80 reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. ONLY CAP RAST had consistently acceptable regression values. **Alastat was recently replaced by 3gAllergy. Studies show 93% agreement between both methods. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. CAP RAST® CAP RAST® Line represents minimum acceptable R2 performance values Alastat/ 3gAllergyTM** RAST/ Modified RAST Newest generation: CAP RAST Ideal Test (Correlation Coefficient) .65 .82 .96 - .98 1.0 Source: Williams PB, Barnes JH, Szeinbach SL, Sullivan T. Analytical precision and accuracy of commercial immunoassays for specific IgE: establishing a standard. J Allergy Clin Immunol. 2000;105(6):1221-1230. Poor Performance For Tests With R2 Below 0.80 “Given the dilution range used in this study, values of R-Square below approximately 0.80 generally reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. Only CAP RAST had consistently acceptable R-Square values, suggesting good performance in their ability to correctly detect the concentrations of specific IgE antibodies across the different samples and allergens.” Predictive Value vs. Skin Prick Testing (SPT)* *Adapted from Reference 1. †CAP RAST Specific IgE blood test was used in this study. 1. Wood RA, et al. J Allergy Clin Immunol. 1999;103:733-779. CAP RAST Authors concluded that CAP RAST Specific IgE blood test and SPT values both exhibited excellent efficiency1 CAP RAST® Return to previous slide Profiles Carefully Designed Profiles engineered to detect >95% of patients with allergy1-3 Regional respiratory profiles include key indoor/outdoor allergens selected according to: Geographic pollen patterns Regional disease prevalence Cross reactivity to other allergens in each inhalant class Allergy March profiles include key food/inhalant allergens Six foods account for 90% of food allergy reactions in children4 Inhalants include common/cross-reactive indoor and outdoor allergens Generally recommended for children ≤6 years of age, based on symptoms CAP RAST Sampson HA, Ho DG. J Allergy Clin Immunol. 1997;100:444-451. Yunginger JW, et al. J Allergy Clin Immunol. 2000;105:1077-1084. Poon AW, et al. Am J Man Care. 1998;4:969-985. AAAAI. The Allergy Report. 2000;3:69. CAP RAST® Understanding Total IgE1 Total IgE often of little practical value when considered alone Levels rarely high when specific IgE titers are not Lacks sensitivity as a rule-out screen: Specific IgE levels may be significantly high when total IgE is low/normal Extremely high total IgE may be seen in some very rare non-atopic conditions2: Certain immunodeficiency diseases (including HIV) IgE myeloma Drug-induced interstitial nephritis Graft-versus-host disease Parasitic diseases Skin diseases in addition to eczema Hyper-IgE syndrome (dermatitis, recurrent pyogenic infection) CAP RAST Fromer LM. J Fam Pract. 2004;suppl:S4-S14. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Understanding Total IgE CAP RAST Return to previous slide *Includes URDs (Upper Respiratory Diseases), CHDs (Childhood Diseases), and LRDs (Lower Respiratory Diseases) 1. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Interpretation of Total IgE* Results Negative (Normal) Positive (Abnormal, Elevated) Negative (Normal) Positive (Abnormal, Elevated) Non-allergic Patient Scenario A Rare1 Scenario B Allergic Patient Scenario C Allergic Patient Scenario D Specific IgE Reading Total IgE Reading Perspectives Perspectives Third-party Perspectives Childhood diseases EAACI AAP Upper respiratory diseases JCAAI (guidelines for chronic rhinitis) AAAAI – The Allergy Report AHRQ (Agency for Healthcare Research and Quality) Multiple textbooks Lower respiratory diseases NIH (asthma guidelines) AAFP (asthma guidelines) FDA (Xolair® indications) “Generally, all individuals with severe, persisting or recurrent possible ‘allergic symptoms’ and individuals with need for continuous prophylactic treatment should be tested for specific allergy regardless of the age of the child.” Høst A, et al. Allergy. 2003;58:559-569. Perspectives Perspectives Return to >> Third-party Perspectives From the European Academy of Allergy and Clinical Immunology1
Slide 55 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide What Is Happening to Treatment? Mechanism of disease is better understood Means that treatments are nearer the root cause Therapeutic specificity is increasing Diseases are different and differentiation is key The mechanism of action of drugs is more specific than ever Diagnostic precision by PCP is necessary New diagnostic technology must be employed Treatment Treatment Treatment Market Review: The Role of Diagnostics in Pharmacotherapy Medications for Respiratory Allergy $$$$$$ Highly specific treatment Highly specific resolution of symptoms due to IgE response only — necessitates perfect diagnosis Binds to IgE; Suppression of IgE response Anti-IgE Vaccine (2003) $$$ Very specific to atopy — necessitates even more accurate diagnosis (Doctors report marginal response for AR with Singulair — could be 65% are not allergic) Specific resolution of symptoms of atopy by blocking another mediator pathway Leukotriene antagonist Montelukast (2002) $$ Introduction of “D” formula creates less specific treatment More specific resolution of symptoms primarily due to atopic etiology — necessitates more specific diagnosis Antihistamine effect with very little anticholinergic effect Non-sedating Antihistamines (1990s) $ Broad (shotgun) Non-specific resolution of symptoms regardless of etiology Antihistamine effect + Anticholinergic effect 1st Generation Antihistamines (1970s) Cost Therapeutic Approach Treatment Results Mode(s) of Action Treatment Progression Treatment Treatment Disease Paradigms Treatment Treatment Hx & PE lab tests diet & exercise pharmacotherapy Diabetes Mellitus Type 2 Hx & PE lipid profile diet & exercise pharmacotherapy Hypercholesterolemia Hx & PE pharmacotherapy CHDs, URDs, LRDs ? IgE profile avoidance CAP RAST: Gain Knowledge to Guide Treatment FDA-cleared quantitative measure of specific IgE Only a single blood draw required Covered under most insurance plans Accuracy superior to RASTTM*1 Next-generation assay offers consistently improved sensitivity,2 De facto standard, documented in >2,700 peer-reviewed publications3 In vitro blood testing and skin prick testing (SPT) viewed as interchangeable4 CAP RAST is available throughout the nation from all major reference and clinical laboratories, including Quest Diagnostics, NS-LIJ & BioReference * RAST is a trademark of Pharmacia Diagnostics. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. Szeinbach SL, et al. Ann Allergy Asthma Immunol. 2001;86:373-381. 3. Johansson SGO. Expert Rev Mol Diagn. 2004;4:273-279. 4. Hamilton RG. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:233-242. CAP RAST® CAP RAST® H. Drevin, 1989 A. Kober, 2004 Solid-phase Protein Binding Capacity Comparison Solid Phase CAP RAST cellulose polymer binds almost 150 times more protein than a passively coated tube, well or bead, and about 250 percent more protein than a paper disc. Accuracy of Immunoassays for Specific IgE *The authors noted that regression values below 0.80 reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. ONLY CAP RAST had consistently acceptable regression values. **Alastat was recently replaced by 3gAllergy. Studies show 93% agreement between both methods. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. CAP RAST® CAP RAST® Line represents minimum acceptable R2 performance values Alastat/ 3gAllergyTM** RAST/ Modified RAST Newest generation: CAP RAST Ideal Test (Correlation Coefficient) .65 .82 .96 - .98 1.0 Source: Williams PB, Barnes JH, Szeinbach SL, Sullivan T. Analytical precision and accuracy of commercial immunoassays for specific IgE: establishing a standard. J Allergy Clin Immunol. 2000;105(6):1221-1230. Poor Performance For Tests With R2 Below 0.80 “Given the dilution range used in this study, values of R-Square below approximately 0.80 generally reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. Only CAP RAST had consistently acceptable R-Square values, suggesting good performance in their ability to correctly detect the concentrations of specific IgE antibodies across the different samples and allergens.” Predictive Value vs. Skin Prick Testing (SPT)* *Adapted from Reference 1. †CAP RAST Specific IgE blood test was used in this study. 1. Wood RA, et al. J Allergy Clin Immunol. 1999;103:733-779. CAP RAST Authors concluded that CAP RAST Specific IgE blood test and SPT values both exhibited excellent efficiency1 CAP RAST® Return to previous slide Profiles Carefully Designed Profiles engineered to detect >95% of patients with allergy1-3 Regional respiratory profiles include key indoor/outdoor allergens selected according to: Geographic pollen patterns Regional disease prevalence Cross reactivity to other allergens in each inhalant class Allergy March profiles include key food/inhalant allergens Six foods account for 90% of food allergy reactions in children4 Inhalants include common/cross-reactive indoor and outdoor allergens Generally recommended for children ≤6 years of age, based on symptoms CAP RAST Sampson HA, Ho DG. J Allergy Clin Immunol. 1997;100:444-451. Yunginger JW, et al. J Allergy Clin Immunol. 2000;105:1077-1084. Poon AW, et al. Am J Man Care. 1998;4:969-985. AAAAI. The Allergy Report. 2000;3:69. CAP RAST® Understanding Total IgE1 Total IgE often of little practical value when considered alone Levels rarely high when specific IgE titers are not Lacks sensitivity as a rule-out screen: Specific IgE levels may be significantly high when total IgE is low/normal Extremely high total IgE may be seen in some very rare non-atopic conditions2: Certain immunodeficiency diseases (including HIV) IgE myeloma Drug-induced interstitial nephritis Graft-versus-host disease Parasitic diseases Skin diseases in addition to eczema Hyper-IgE syndrome (dermatitis, recurrent pyogenic infection) CAP RAST Fromer LM. J Fam Pract. 2004;suppl:S4-S14. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Understanding Total IgE CAP RAST Return to previous slide *Includes URDs (Upper Respiratory Diseases), CHDs (Childhood Diseases), and LRDs (Lower Respiratory Diseases) 1. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Interpretation of Total IgE* Results Negative (Normal) Positive (Abnormal, Elevated) Negative (Normal) Positive (Abnormal, Elevated) Non-allergic Patient Scenario A Rare1 Scenario B Allergic Patient Scenario C Allergic Patient Scenario D Specific IgE Reading Total IgE Reading Perspectives Perspectives Third-party Perspectives Childhood diseases EAACI AAP Upper respiratory diseases JCAAI (guidelines for chronic rhinitis) AAAAI – The Allergy Report AHRQ (Agency for Healthcare Research and Quality) Multiple textbooks Lower respiratory diseases NIH (asthma guidelines) AAFP (asthma guidelines) FDA (Xolair® indications) “Generally, all individuals with severe, persisting or recurrent possible ‘allergic symptoms’ and individuals with need for continuous prophylactic treatment should be tested for specific allergy regardless of the age of the child.” Høst A, et al. Allergy. 2003;58:559-569. Perspectives Perspectives Return to >> Third-party Perspectives From the European Academy of Allergy and Clinical Immunology1 AAP Pediatric Update. 2001;22:1-8. Perspectives Perspectives From the American Academy of Pediatrics1 Panel Discussion: Recent Advances in Allergy Hugh A. Sampson, MD: “The pediatrician could certainly order the blood test initially to see whether or not there were significant levels of antibody to milk, egg, or peanut in these children with atopic dermatitis….” Laurie J. Smith, MD: “It’s important to specify, however, that the only in vitro test with which such diagnostic assumptions can be made is with the CAP RAST and no other in vitro test that is available.” Return to >> Third-party Perspectives
Slide 56 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide What Is Happening to Treatment? Mechanism of disease is better understood Means that treatments are nearer the root cause Therapeutic specificity is increasing Diseases are different and differentiation is key The mechanism of action of drugs is more specific than ever Diagnostic precision by PCP is necessary New diagnostic technology must be employed Treatment Treatment Treatment Market Review: The Role of Diagnostics in Pharmacotherapy Medications for Respiratory Allergy $$$$$$ Highly specific treatment Highly specific resolution of symptoms due to IgE response only — necessitates perfect diagnosis Binds to IgE; Suppression of IgE response Anti-IgE Vaccine (2003) $$$ Very specific to atopy — necessitates even more accurate diagnosis (Doctors report marginal response for AR with Singulair — could be 65% are not allergic) Specific resolution of symptoms of atopy by blocking another mediator pathway Leukotriene antagonist Montelukast (2002) $$ Introduction of “D” formula creates less specific treatment More specific resolution of symptoms primarily due to atopic etiology — necessitates more specific diagnosis Antihistamine effect with very little anticholinergic effect Non-sedating Antihistamines (1990s) $ Broad (shotgun) Non-specific resolution of symptoms regardless of etiology Antihistamine effect + Anticholinergic effect 1st Generation Antihistamines (1970s) Cost Therapeutic Approach Treatment Results Mode(s) of Action Treatment Progression Treatment Treatment Disease Paradigms Treatment Treatment Hx & PE lab tests diet & exercise pharmacotherapy Diabetes Mellitus Type 2 Hx & PE lipid profile diet & exercise pharmacotherapy Hypercholesterolemia Hx & PE pharmacotherapy CHDs, URDs, LRDs ? IgE profile avoidance CAP RAST: Gain Knowledge to Guide Treatment FDA-cleared quantitative measure of specific IgE Only a single blood draw required Covered under most insurance plans Accuracy superior to RASTTM*1 Next-generation assay offers consistently improved sensitivity,2 De facto standard, documented in >2,700 peer-reviewed publications3 In vitro blood testing and skin prick testing (SPT) viewed as interchangeable4 CAP RAST is available throughout the nation from all major reference and clinical laboratories, including Quest Diagnostics, NS-LIJ & BioReference * RAST is a trademark of Pharmacia Diagnostics. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. Szeinbach SL, et al. Ann Allergy Asthma Immunol. 2001;86:373-381. 3. Johansson SGO. Expert Rev Mol Diagn. 2004;4:273-279. 4. Hamilton RG. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:233-242. CAP RAST® CAP RAST® H. Drevin, 1989 A. Kober, 2004 Solid-phase Protein Binding Capacity Comparison Solid Phase CAP RAST cellulose polymer binds almost 150 times more protein than a passively coated tube, well or bead, and about 250 percent more protein than a paper disc. Accuracy of Immunoassays for Specific IgE *The authors noted that regression values below 0.80 reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. ONLY CAP RAST had consistently acceptable regression values. **Alastat was recently replaced by 3gAllergy. Studies show 93% agreement between both methods. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. CAP RAST® CAP RAST® Line represents minimum acceptable R2 performance values Alastat/ 3gAllergyTM** RAST/ Modified RAST Newest generation: CAP RAST Ideal Test (Correlation Coefficient) .65 .82 .96 - .98 1.0 Source: Williams PB, Barnes JH, Szeinbach SL, Sullivan T. Analytical precision and accuracy of commercial immunoassays for specific IgE: establishing a standard. J Allergy Clin Immunol. 2000;105(6):1221-1230. Poor Performance For Tests With R2 Below 0.80 “Given the dilution range used in this study, values of R-Square below approximately 0.80 generally reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. Only CAP RAST had consistently acceptable R-Square values, suggesting good performance in their ability to correctly detect the concentrations of specific IgE antibodies across the different samples and allergens.” Predictive Value vs. Skin Prick Testing (SPT)* *Adapted from Reference 1. †CAP RAST Specific IgE blood test was used in this study. 1. Wood RA, et al. J Allergy Clin Immunol. 1999;103:733-779. CAP RAST Authors concluded that CAP RAST Specific IgE blood test and SPT values both exhibited excellent efficiency1 CAP RAST® Return to previous slide Profiles Carefully Designed Profiles engineered to detect >95% of patients with allergy1-3 Regional respiratory profiles include key indoor/outdoor allergens selected according to: Geographic pollen patterns Regional disease prevalence Cross reactivity to other allergens in each inhalant class Allergy March profiles include key food/inhalant allergens Six foods account for 90% of food allergy reactions in children4 Inhalants include common/cross-reactive indoor and outdoor allergens Generally recommended for children ≤6 years of age, based on symptoms CAP RAST Sampson HA, Ho DG. J Allergy Clin Immunol. 1997;100:444-451. Yunginger JW, et al. J Allergy Clin Immunol. 2000;105:1077-1084. Poon AW, et al. Am J Man Care. 1998;4:969-985. AAAAI. The Allergy Report. 2000;3:69. CAP RAST® Understanding Total IgE1 Total IgE often of little practical value when considered alone Levels rarely high when specific IgE titers are not Lacks sensitivity as a rule-out screen: Specific IgE levels may be significantly high when total IgE is low/normal Extremely high total IgE may be seen in some very rare non-atopic conditions2: Certain immunodeficiency diseases (including HIV) IgE myeloma Drug-induced interstitial nephritis Graft-versus-host disease Parasitic diseases Skin diseases in addition to eczema Hyper-IgE syndrome (dermatitis, recurrent pyogenic infection) CAP RAST Fromer LM. J Fam Pract. 2004;suppl:S4-S14. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Understanding Total IgE CAP RAST Return to previous slide *Includes URDs (Upper Respiratory Diseases), CHDs (Childhood Diseases), and LRDs (Lower Respiratory Diseases) 1. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Interpretation of Total IgE* Results Negative (Normal) Positive (Abnormal, Elevated) Negative (Normal) Positive (Abnormal, Elevated) Non-allergic Patient Scenario A Rare1 Scenario B Allergic Patient Scenario C Allergic Patient Scenario D Specific IgE Reading Total IgE Reading Perspectives Perspectives Third-party Perspectives Childhood diseases EAACI AAP Upper respiratory diseases JCAAI (guidelines for chronic rhinitis) AAAAI – The Allergy Report AHRQ (Agency for Healthcare Research and Quality) Multiple textbooks Lower respiratory diseases NIH (asthma guidelines) AAFP (asthma guidelines) FDA (Xolair® indications) “Generally, all individuals with severe, persisting or recurrent possible ‘allergic symptoms’ and individuals with need for continuous prophylactic treatment should be tested for specific allergy regardless of the age of the child.” Høst A, et al. Allergy. 2003;58:559-569. Perspectives Perspectives Return to >> Third-party Perspectives From the European Academy of Allergy and Clinical Immunology1 AAP Pediatric Update. 2001;22:1-8. Perspectives Perspectives From the American Academy of Pediatrics1 Panel Discussion: Recent Advances in Allergy Hugh A. Sampson, MD: “The pediatrician could certainly order the blood test initially to see whether or not there were significant levels of antibody to milk, egg, or peanut in these children with atopic dermatitis….” Laurie J. Smith, MD: “It’s important to specify, however, that the only in vitro test with which such diagnostic assumptions can be made is with the CAP RAST and no other in vitro test that is available.” Return to >> Third-party Perspectives Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Perspectives Perspectives From the Joint Council of Allergy, Asthma, and Immunology1 Rhinitis should be classified by etiology as allergic or non-allergic Since approximately 50% of patients with rhinitis do not have allergic rhinitis, other potential causes must be ruled out Return to >> Third-party Perspectives
Slide 57 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide What Is Happening to Treatment? Mechanism of disease is better understood Means that treatments are nearer the root cause Therapeutic specificity is increasing Diseases are different and differentiation is key The mechanism of action of drugs is more specific than ever Diagnostic precision by PCP is necessary New diagnostic technology must be employed Treatment Treatment Treatment Market Review: The Role of Diagnostics in Pharmacotherapy Medications for Respiratory Allergy $$$$$$ Highly specific treatment Highly specific resolution of symptoms due to IgE response only — necessitates perfect diagnosis Binds to IgE; Suppression of IgE response Anti-IgE Vaccine (2003) $$$ Very specific to atopy — necessitates even more accurate diagnosis (Doctors report marginal response for AR with Singulair — could be 65% are not allergic) Specific resolution of symptoms of atopy by blocking another mediator pathway Leukotriene antagonist Montelukast (2002) $$ Introduction of “D” formula creates less specific treatment More specific resolution of symptoms primarily due to atopic etiology — necessitates more specific diagnosis Antihistamine effect with very little anticholinergic effect Non-sedating Antihistamines (1990s) $ Broad (shotgun) Non-specific resolution of symptoms regardless of etiology Antihistamine effect + Anticholinergic effect 1st Generation Antihistamines (1970s) Cost Therapeutic Approach Treatment Results Mode(s) of Action Treatment Progression Treatment Treatment Disease Paradigms Treatment Treatment Hx & PE lab tests diet & exercise pharmacotherapy Diabetes Mellitus Type 2 Hx & PE lipid profile diet & exercise pharmacotherapy Hypercholesterolemia Hx & PE pharmacotherapy CHDs, URDs, LRDs ? IgE profile avoidance CAP RAST: Gain Knowledge to Guide Treatment FDA-cleared quantitative measure of specific IgE Only a single blood draw required Covered under most insurance plans Accuracy superior to RASTTM*1 Next-generation assay offers consistently improved sensitivity,2 De facto standard, documented in >2,700 peer-reviewed publications3 In vitro blood testing and skin prick testing (SPT) viewed as interchangeable4 CAP RAST is available throughout the nation from all major reference and clinical laboratories, including Quest Diagnostics, NS-LIJ & BioReference * RAST is a trademark of Pharmacia Diagnostics. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. Szeinbach SL, et al. Ann Allergy Asthma Immunol. 2001;86:373-381. 3. Johansson SGO. Expert Rev Mol Diagn. 2004;4:273-279. 4. Hamilton RG. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:233-242. CAP RAST® CAP RAST® H. Drevin, 1989 A. Kober, 2004 Solid-phase Protein Binding Capacity Comparison Solid Phase CAP RAST cellulose polymer binds almost 150 times more protein than a passively coated tube, well or bead, and about 250 percent more protein than a paper disc. Accuracy of Immunoassays for Specific IgE *The authors noted that regression values below 0.80 reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. ONLY CAP RAST had consistently acceptable regression values. **Alastat was recently replaced by 3gAllergy. Studies show 93% agreement between both methods. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. CAP RAST® CAP RAST® Line represents minimum acceptable R2 performance values Alastat/ 3gAllergyTM** RAST/ Modified RAST Newest generation: CAP RAST Ideal Test (Correlation Coefficient) .65 .82 .96 - .98 1.0 Source: Williams PB, Barnes JH, Szeinbach SL, Sullivan T. Analytical precision and accuracy of commercial immunoassays for specific IgE: establishing a standard. J Allergy Clin Immunol. 2000;105(6):1221-1230. Poor Performance For Tests With R2 Below 0.80 “Given the dilution range used in this study, values of R-Square below approximately 0.80 generally reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. Only CAP RAST had consistently acceptable R-Square values, suggesting good performance in their ability to correctly detect the concentrations of specific IgE antibodies across the different samples and allergens.” Predictive Value vs. Skin Prick Testing (SPT)* *Adapted from Reference 1. †CAP RAST Specific IgE blood test was used in this study. 1. Wood RA, et al. J Allergy Clin Immunol. 1999;103:733-779. CAP RAST Authors concluded that CAP RAST Specific IgE blood test and SPT values both exhibited excellent efficiency1 CAP RAST® Return to previous slide Profiles Carefully Designed Profiles engineered to detect >95% of patients with allergy1-3 Regional respiratory profiles include key indoor/outdoor allergens selected according to: Geographic pollen patterns Regional disease prevalence Cross reactivity to other allergens in each inhalant class Allergy March profiles include key food/inhalant allergens Six foods account for 90% of food allergy reactions in children4 Inhalants include common/cross-reactive indoor and outdoor allergens Generally recommended for children ≤6 years of age, based on symptoms CAP RAST Sampson HA, Ho DG. J Allergy Clin Immunol. 1997;100:444-451. Yunginger JW, et al. J Allergy Clin Immunol. 2000;105:1077-1084. Poon AW, et al. Am J Man Care. 1998;4:969-985. AAAAI. The Allergy Report. 2000;3:69. CAP RAST® Understanding Total IgE1 Total IgE often of little practical value when considered alone Levels rarely high when specific IgE titers are not Lacks sensitivity as a rule-out screen: Specific IgE levels may be significantly high when total IgE is low/normal Extremely high total IgE may be seen in some very rare non-atopic conditions2: Certain immunodeficiency diseases (including HIV) IgE myeloma Drug-induced interstitial nephritis Graft-versus-host disease Parasitic diseases Skin diseases in addition to eczema Hyper-IgE syndrome (dermatitis, recurrent pyogenic infection) CAP RAST Fromer LM. J Fam Pract. 2004;suppl:S4-S14. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Understanding Total IgE CAP RAST Return to previous slide *Includes URDs (Upper Respiratory Diseases), CHDs (Childhood Diseases), and LRDs (Lower Respiratory Diseases) 1. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Interpretation of Total IgE* Results Negative (Normal) Positive (Abnormal, Elevated) Negative (Normal) Positive (Abnormal, Elevated) Non-allergic Patient Scenario A Rare1 Scenario B Allergic Patient Scenario C Allergic Patient Scenario D Specific IgE Reading Total IgE Reading Perspectives Perspectives Third-party Perspectives Childhood diseases EAACI AAP Upper respiratory diseases JCAAI (guidelines for chronic rhinitis) AAAAI – The Allergy Report AHRQ (Agency for Healthcare Research and Quality) Multiple textbooks Lower respiratory diseases NIH (asthma guidelines) AAFP (asthma guidelines) FDA (Xolair® indications) “Generally, all individuals with severe, persisting or recurrent possible ‘allergic symptoms’ and individuals with need for continuous prophylactic treatment should be tested for specific allergy regardless of the age of the child.” Høst A, et al. Allergy. 2003;58:559-569. Perspectives Perspectives Return to >> Third-party Perspectives From the European Academy of Allergy and Clinical Immunology1 AAP Pediatric Update. 2001;22:1-8. Perspectives Perspectives From the American Academy of Pediatrics1 Panel Discussion: Recent Advances in Allergy Hugh A. Sampson, MD: “The pediatrician could certainly order the blood test initially to see whether or not there were significant levels of antibody to milk, egg, or peanut in these children with atopic dermatitis….” Laurie J. Smith, MD: “It’s important to specify, however, that the only in vitro test with which such diagnostic assumptions can be made is with the CAP RAST and no other in vitro test that is available.” Return to >> Third-party Perspectives Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Perspectives Perspectives From the Joint Council of Allergy, Asthma, and Immunology1 Rhinitis should be classified by etiology as allergic or non-allergic Since approximately 50% of patients with rhinitis do not have allergic rhinitis, other potential causes must be ruled out Return to >> Third-party Perspectives Perspectives Perspectives AAAAI. The Allergy Report. 2000;1:31. From the American Academy of Allergy, Asthma & Immunology1 “Diagnostic evaluation, including specific testing, is necessary to: Confirm the allergic diagnosis Differentiate allergic disorders from other diseases Uncover previously unsuspected allergens Guide treatment” Return to >> Third-party Perspectives
Slide 58 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide What Is Happening to Treatment? Mechanism of disease is better understood Means that treatments are nearer the root cause Therapeutic specificity is increasing Diseases are different and differentiation is key The mechanism of action of drugs is more specific than ever Diagnostic precision by PCP is necessary New diagnostic technology must be employed Treatment Treatment Treatment Market Review: The Role of Diagnostics in Pharmacotherapy Medications for Respiratory Allergy $$$$$$ Highly specific treatment Highly specific resolution of symptoms due to IgE response only — necessitates perfect diagnosis Binds to IgE; Suppression of IgE response Anti-IgE Vaccine (2003) $$$ Very specific to atopy — necessitates even more accurate diagnosis (Doctors report marginal response for AR with Singulair — could be 65% are not allergic) Specific resolution of symptoms of atopy by blocking another mediator pathway Leukotriene antagonist Montelukast (2002) $$ Introduction of “D” formula creates less specific treatment More specific resolution of symptoms primarily due to atopic etiology — necessitates more specific diagnosis Antihistamine effect with very little anticholinergic effect Non-sedating Antihistamines (1990s) $ Broad (shotgun) Non-specific resolution of symptoms regardless of etiology Antihistamine effect + Anticholinergic effect 1st Generation Antihistamines (1970s) Cost Therapeutic Approach Treatment Results Mode(s) of Action Treatment Progression Treatment Treatment Disease Paradigms Treatment Treatment Hx & PE lab tests diet & exercise pharmacotherapy Diabetes Mellitus Type 2 Hx & PE lipid profile diet & exercise pharmacotherapy Hypercholesterolemia Hx & PE pharmacotherapy CHDs, URDs, LRDs ? IgE profile avoidance CAP RAST: Gain Knowledge to Guide Treatment FDA-cleared quantitative measure of specific IgE Only a single blood draw required Covered under most insurance plans Accuracy superior to RASTTM*1 Next-generation assay offers consistently improved sensitivity,2 De facto standard, documented in >2,700 peer-reviewed publications3 In vitro blood testing and skin prick testing (SPT) viewed as interchangeable4 CAP RAST is available throughout the nation from all major reference and clinical laboratories, including Quest Diagnostics, NS-LIJ & BioReference * RAST is a trademark of Pharmacia Diagnostics. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. Szeinbach SL, et al. Ann Allergy Asthma Immunol. 2001;86:373-381. 3. Johansson SGO. Expert Rev Mol Diagn. 2004;4:273-279. 4. Hamilton RG. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:233-242. CAP RAST® CAP RAST® H. Drevin, 1989 A. Kober, 2004 Solid-phase Protein Binding Capacity Comparison Solid Phase CAP RAST cellulose polymer binds almost 150 times more protein than a passively coated tube, well or bead, and about 250 percent more protein than a paper disc. Accuracy of Immunoassays for Specific IgE *The authors noted that regression values below 0.80 reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. ONLY CAP RAST had consistently acceptable regression values. **Alastat was recently replaced by 3gAllergy. Studies show 93% agreement between both methods. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. CAP RAST® CAP RAST® Line represents minimum acceptable R2 performance values Alastat/ 3gAllergyTM** RAST/ Modified RAST Newest generation: CAP RAST Ideal Test (Correlation Coefficient) .65 .82 .96 - .98 1.0 Source: Williams PB, Barnes JH, Szeinbach SL, Sullivan T. Analytical precision and accuracy of commercial immunoassays for specific IgE: establishing a standard. J Allergy Clin Immunol. 2000;105(6):1221-1230. Poor Performance For Tests With R2 Below 0.80 “Given the dilution range used in this study, values of R-Square below approximately 0.80 generally reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. Only CAP RAST had consistently acceptable R-Square values, suggesting good performance in their ability to correctly detect the concentrations of specific IgE antibodies across the different samples and allergens.” Predictive Value vs. Skin Prick Testing (SPT)* *Adapted from Reference 1. †CAP RAST Specific IgE blood test was used in this study. 1. Wood RA, et al. J Allergy Clin Immunol. 1999;103:733-779. CAP RAST Authors concluded that CAP RAST Specific IgE blood test and SPT values both exhibited excellent efficiency1 CAP RAST® Return to previous slide Profiles Carefully Designed Profiles engineered to detect >95% of patients with allergy1-3 Regional respiratory profiles include key indoor/outdoor allergens selected according to: Geographic pollen patterns Regional disease prevalence Cross reactivity to other allergens in each inhalant class Allergy March profiles include key food/inhalant allergens Six foods account for 90% of food allergy reactions in children4 Inhalants include common/cross-reactive indoor and outdoor allergens Generally recommended for children ≤6 years of age, based on symptoms CAP RAST Sampson HA, Ho DG. J Allergy Clin Immunol. 1997;100:444-451. Yunginger JW, et al. J Allergy Clin Immunol. 2000;105:1077-1084. Poon AW, et al. Am J Man Care. 1998;4:969-985. AAAAI. The Allergy Report. 2000;3:69. CAP RAST® Understanding Total IgE1 Total IgE often of little practical value when considered alone Levels rarely high when specific IgE titers are not Lacks sensitivity as a rule-out screen: Specific IgE levels may be significantly high when total IgE is low/normal Extremely high total IgE may be seen in some very rare non-atopic conditions2: Certain immunodeficiency diseases (including HIV) IgE myeloma Drug-induced interstitial nephritis Graft-versus-host disease Parasitic diseases Skin diseases in addition to eczema Hyper-IgE syndrome (dermatitis, recurrent pyogenic infection) CAP RAST Fromer LM. J Fam Pract. 2004;suppl:S4-S14. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Understanding Total IgE CAP RAST Return to previous slide *Includes URDs (Upper Respiratory Diseases), CHDs (Childhood Diseases), and LRDs (Lower Respiratory Diseases) 1. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Interpretation of Total IgE* Results Negative (Normal) Positive (Abnormal, Elevated) Negative (Normal) Positive (Abnormal, Elevated) Non-allergic Patient Scenario A Rare1 Scenario B Allergic Patient Scenario C Allergic Patient Scenario D Specific IgE Reading Total IgE Reading Perspectives Perspectives Third-party Perspectives Childhood diseases EAACI AAP Upper respiratory diseases JCAAI (guidelines for chronic rhinitis) AAAAI – The Allergy Report AHRQ (Agency for Healthcare Research and Quality) Multiple textbooks Lower respiratory diseases NIH (asthma guidelines) AAFP (asthma guidelines) FDA (Xolair® indications) “Generally, all individuals with severe, persisting or recurrent possible ‘allergic symptoms’ and individuals with need for continuous prophylactic treatment should be tested for specific allergy regardless of the age of the child.” Høst A, et al. Allergy. 2003;58:559-569. Perspectives Perspectives Return to >> Third-party Perspectives From the European Academy of Allergy and Clinical Immunology1 AAP Pediatric Update. 2001;22:1-8. Perspectives Perspectives From the American Academy of Pediatrics1 Panel Discussion: Recent Advances in Allergy Hugh A. Sampson, MD: “The pediatrician could certainly order the blood test initially to see whether or not there were significant levels of antibody to milk, egg, or peanut in these children with atopic dermatitis….” Laurie J. Smith, MD: “It’s important to specify, however, that the only in vitro test with which such diagnostic assumptions can be made is with the CAP RAST and no other in vitro test that is available.” Return to >> Third-party Perspectives Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Perspectives Perspectives From the Joint Council of Allergy, Asthma, and Immunology1 Rhinitis should be classified by etiology as allergic or non-allergic Since approximately 50% of patients with rhinitis do not have allergic rhinitis, other potential causes must be ruled out Return to >> Third-party Perspectives Perspectives Perspectives AAAAI. The Allergy Report. 2000;1:31. From the American Academy of Allergy, Asthma & Immunology1 “Diagnostic evaluation, including specific testing, is necessary to: Confirm the allergic diagnosis Differentiate allergic disorders from other diseases Uncover previously unsuspected allergens Guide treatment” Return to >> Third-party Perspectives “Given the absence of studies to differentiate nonallergic rhinitis, diagnostic testing rather than symptoms or signs is necessary to differentiate isolated vasomotor or nonallergic rhinitis from allergic rhinitis.” AHRQ. Management of allergic and nonallergic rhinitis. May 2002. AHRQ Pub. No. 02-E023. Perspectives Perspectives From the Agency for Healthcare Research and Quality1 Return to >> Third-party Perspectives
Slide 59 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide What Is Happening to Treatment? Mechanism of disease is better understood Means that treatments are nearer the root cause Therapeutic specificity is increasing Diseases are different and differentiation is key The mechanism of action of drugs is more specific than ever Diagnostic precision by PCP is necessary New diagnostic technology must be employed Treatment Treatment Treatment Market Review: The Role of Diagnostics in Pharmacotherapy Medications for Respiratory Allergy $$$$$$ Highly specific treatment Highly specific resolution of symptoms due to IgE response only — necessitates perfect diagnosis Binds to IgE; Suppression of IgE response Anti-IgE Vaccine (2003) $$$ Very specific to atopy — necessitates even more accurate diagnosis (Doctors report marginal response for AR with Singulair — could be 65% are not allergic) Specific resolution of symptoms of atopy by blocking another mediator pathway Leukotriene antagonist Montelukast (2002) $$ Introduction of “D” formula creates less specific treatment More specific resolution of symptoms primarily due to atopic etiology — necessitates more specific diagnosis Antihistamine effect with very little anticholinergic effect Non-sedating Antihistamines (1990s) $ Broad (shotgun) Non-specific resolution of symptoms regardless of etiology Antihistamine effect + Anticholinergic effect 1st Generation Antihistamines (1970s) Cost Therapeutic Approach Treatment Results Mode(s) of Action Treatment Progression Treatment Treatment Disease Paradigms Treatment Treatment Hx & PE lab tests diet & exercise pharmacotherapy Diabetes Mellitus Type 2 Hx & PE lipid profile diet & exercise pharmacotherapy Hypercholesterolemia Hx & PE pharmacotherapy CHDs, URDs, LRDs ? IgE profile avoidance CAP RAST: Gain Knowledge to Guide Treatment FDA-cleared quantitative measure of specific IgE Only a single blood draw required Covered under most insurance plans Accuracy superior to RASTTM*1 Next-generation assay offers consistently improved sensitivity,2 De facto standard, documented in >2,700 peer-reviewed publications3 In vitro blood testing and skin prick testing (SPT) viewed as interchangeable4 CAP RAST is available throughout the nation from all major reference and clinical laboratories, including Quest Diagnostics, NS-LIJ & BioReference * RAST is a trademark of Pharmacia Diagnostics. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. Szeinbach SL, et al. Ann Allergy Asthma Immunol. 2001;86:373-381. 3. Johansson SGO. Expert Rev Mol Diagn. 2004;4:273-279. 4. Hamilton RG. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:233-242. CAP RAST® CAP RAST® H. Drevin, 1989 A. Kober, 2004 Solid-phase Protein Binding Capacity Comparison Solid Phase CAP RAST cellulose polymer binds almost 150 times more protein than a passively coated tube, well or bead, and about 250 percent more protein than a paper disc. Accuracy of Immunoassays for Specific IgE *The authors noted that regression values below 0.80 reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. ONLY CAP RAST had consistently acceptable regression values. **Alastat was recently replaced by 3gAllergy. Studies show 93% agreement between both methods. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. CAP RAST® CAP RAST® Line represents minimum acceptable R2 performance values Alastat/ 3gAllergyTM** RAST/ Modified RAST Newest generation: CAP RAST Ideal Test (Correlation Coefficient) .65 .82 .96 - .98 1.0 Source: Williams PB, Barnes JH, Szeinbach SL, Sullivan T. Analytical precision and accuracy of commercial immunoassays for specific IgE: establishing a standard. J Allergy Clin Immunol. 2000;105(6):1221-1230. Poor Performance For Tests With R2 Below 0.80 “Given the dilution range used in this study, values of R-Square below approximately 0.80 generally reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. Only CAP RAST had consistently acceptable R-Square values, suggesting good performance in their ability to correctly detect the concentrations of specific IgE antibodies across the different samples and allergens.” Predictive Value vs. Skin Prick Testing (SPT)* *Adapted from Reference 1. †CAP RAST Specific IgE blood test was used in this study. 1. Wood RA, et al. J Allergy Clin Immunol. 1999;103:733-779. CAP RAST Authors concluded that CAP RAST Specific IgE blood test and SPT values both exhibited excellent efficiency1 CAP RAST® Return to previous slide Profiles Carefully Designed Profiles engineered to detect >95% of patients with allergy1-3 Regional respiratory profiles include key indoor/outdoor allergens selected according to: Geographic pollen patterns Regional disease prevalence Cross reactivity to other allergens in each inhalant class Allergy March profiles include key food/inhalant allergens Six foods account for 90% of food allergy reactions in children4 Inhalants include common/cross-reactive indoor and outdoor allergens Generally recommended for children ≤6 years of age, based on symptoms CAP RAST Sampson HA, Ho DG. J Allergy Clin Immunol. 1997;100:444-451. Yunginger JW, et al. J Allergy Clin Immunol. 2000;105:1077-1084. Poon AW, et al. Am J Man Care. 1998;4:969-985. AAAAI. The Allergy Report. 2000;3:69. CAP RAST® Understanding Total IgE1 Total IgE often of little practical value when considered alone Levels rarely high when specific IgE titers are not Lacks sensitivity as a rule-out screen: Specific IgE levels may be significantly high when total IgE is low/normal Extremely high total IgE may be seen in some very rare non-atopic conditions2: Certain immunodeficiency diseases (including HIV) IgE myeloma Drug-induced interstitial nephritis Graft-versus-host disease Parasitic diseases Skin diseases in addition to eczema Hyper-IgE syndrome (dermatitis, recurrent pyogenic infection) CAP RAST Fromer LM. J Fam Pract. 2004;suppl:S4-S14. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Understanding Total IgE CAP RAST Return to previous slide *Includes URDs (Upper Respiratory Diseases), CHDs (Childhood Diseases), and LRDs (Lower Respiratory Diseases) 1. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Interpretation of Total IgE* Results Negative (Normal) Positive (Abnormal, Elevated) Negative (Normal) Positive (Abnormal, Elevated) Non-allergic Patient Scenario A Rare1 Scenario B Allergic Patient Scenario C Allergic Patient Scenario D Specific IgE Reading Total IgE Reading Perspectives Perspectives Third-party Perspectives Childhood diseases EAACI AAP Upper respiratory diseases JCAAI (guidelines for chronic rhinitis) AAAAI – The Allergy Report AHRQ (Agency for Healthcare Research and Quality) Multiple textbooks Lower respiratory diseases NIH (asthma guidelines) AAFP (asthma guidelines) FDA (Xolair® indications) “Generally, all individuals with severe, persisting or recurrent possible ‘allergic symptoms’ and individuals with need for continuous prophylactic treatment should be tested for specific allergy regardless of the age of the child.” Høst A, et al. Allergy. 2003;58:559-569. Perspectives Perspectives Return to >> Third-party Perspectives From the European Academy of Allergy and Clinical Immunology1 AAP Pediatric Update. 2001;22:1-8. Perspectives Perspectives From the American Academy of Pediatrics1 Panel Discussion: Recent Advances in Allergy Hugh A. Sampson, MD: “The pediatrician could certainly order the blood test initially to see whether or not there were significant levels of antibody to milk, egg, or peanut in these children with atopic dermatitis….” Laurie J. Smith, MD: “It’s important to specify, however, that the only in vitro test with which such diagnostic assumptions can be made is with the CAP RAST and no other in vitro test that is available.” Return to >> Third-party Perspectives Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Perspectives Perspectives From the Joint Council of Allergy, Asthma, and Immunology1 Rhinitis should be classified by etiology as allergic or non-allergic Since approximately 50% of patients with rhinitis do not have allergic rhinitis, other potential causes must be ruled out Return to >> Third-party Perspectives Perspectives Perspectives AAAAI. The Allergy Report. 2000;1:31. From the American Academy of Allergy, Asthma & Immunology1 “Diagnostic evaluation, including specific testing, is necessary to: Confirm the allergic diagnosis Differentiate allergic disorders from other diseases Uncover previously unsuspected allergens Guide treatment” Return to >> Third-party Perspectives “Given the absence of studies to differentiate nonallergic rhinitis, diagnostic testing rather than symptoms or signs is necessary to differentiate isolated vasomotor or nonallergic rhinitis from allergic rhinitis.” AHRQ. Management of allergic and nonallergic rhinitis. May 2002. AHRQ Pub. No. 02-E023. Perspectives Perspectives From the Agency for Healthcare Research and Quality1 Return to >> Third-party Perspectives Perspectives AAFP. Asthma & Allergy Resource Guide. 2004:11-13. Perspectives From the American Academy of Family Physicians1 “Determining whether and how allergies play a role in a patient’s asthma is an important part of the clinical picture.” “Family physicians are in an ideal position to consider the full spectrum of potential allergic and non-allergic triggers in their evaluation of patients who have asthma.” “The CAP RAST serum specific immunoglobulin E (IgE) assay may also be appropriate for patients in whom skin testing is not an option….Quantitative testing…may be more useful because it identifies a patient’s specific causative allergens. CAP RAST testing is often less expensive than RAST and is a fairly simple way for family physicians to screen patients before referral to an allergist.” Return to >> Third-party Perspectives
Slide 60 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide What Is Happening to Treatment? Mechanism of disease is better understood Means that treatments are nearer the root cause Therapeutic specificity is increasing Diseases are different and differentiation is key The mechanism of action of drugs is more specific than ever Diagnostic precision by PCP is necessary New diagnostic technology must be employed Treatment Treatment Treatment Market Review: The Role of Diagnostics in Pharmacotherapy Medications for Respiratory Allergy $$$$$$ Highly specific treatment Highly specific resolution of symptoms due to IgE response only — necessitates perfect diagnosis Binds to IgE; Suppression of IgE response Anti-IgE Vaccine (2003) $$$ Very specific to atopy — necessitates even more accurate diagnosis (Doctors report marginal response for AR with Singulair — could be 65% are not allergic) Specific resolution of symptoms of atopy by blocking another mediator pathway Leukotriene antagonist Montelukast (2002) $$ Introduction of “D” formula creates less specific treatment More specific resolution of symptoms primarily due to atopic etiology — necessitates more specific diagnosis Antihistamine effect with very little anticholinergic effect Non-sedating Antihistamines (1990s) $ Broad (shotgun) Non-specific resolution of symptoms regardless of etiology Antihistamine effect + Anticholinergic effect 1st Generation Antihistamines (1970s) Cost Therapeutic Approach Treatment Results Mode(s) of Action Treatment Progression Treatment Treatment Disease Paradigms Treatment Treatment Hx & PE lab tests diet & exercise pharmacotherapy Diabetes Mellitus Type 2 Hx & PE lipid profile diet & exercise pharmacotherapy Hypercholesterolemia Hx & PE pharmacotherapy CHDs, URDs, LRDs ? IgE profile avoidance CAP RAST: Gain Knowledge to Guide Treatment FDA-cleared quantitative measure of specific IgE Only a single blood draw required Covered under most insurance plans Accuracy superior to RASTTM*1 Next-generation assay offers consistently improved sensitivity,2 De facto standard, documented in >2,700 peer-reviewed publications3 In vitro blood testing and skin prick testing (SPT) viewed as interchangeable4 CAP RAST is available throughout the nation from all major reference and clinical laboratories, including Quest Diagnostics, NS-LIJ & BioReference * RAST is a trademark of Pharmacia Diagnostics. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. Szeinbach SL, et al. Ann Allergy Asthma Immunol. 2001;86:373-381. 3. Johansson SGO. Expert Rev Mol Diagn. 2004;4:273-279. 4. Hamilton RG. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:233-242. CAP RAST® CAP RAST® H. Drevin, 1989 A. Kober, 2004 Solid-phase Protein Binding Capacity Comparison Solid Phase CAP RAST cellulose polymer binds almost 150 times more protein than a passively coated tube, well or bead, and about 250 percent more protein than a paper disc. Accuracy of Immunoassays for Specific IgE *The authors noted that regression values below 0.80 reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. ONLY CAP RAST had consistently acceptable regression values. **Alastat was recently replaced by 3gAllergy. Studies show 93% agreement between both methods. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. CAP RAST® CAP RAST® Line represents minimum acceptable R2 performance values Alastat/ 3gAllergyTM** RAST/ Modified RAST Newest generation: CAP RAST Ideal Test (Correlation Coefficient) .65 .82 .96 - .98 1.0 Source: Williams PB, Barnes JH, Szeinbach SL, Sullivan T. Analytical precision and accuracy of commercial immunoassays for specific IgE: establishing a standard. J Allergy Clin Immunol. 2000;105(6):1221-1230. Poor Performance For Tests With R2 Below 0.80 “Given the dilution range used in this study, values of R-Square below approximately 0.80 generally reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. Only CAP RAST had consistently acceptable R-Square values, suggesting good performance in their ability to correctly detect the concentrations of specific IgE antibodies across the different samples and allergens.” Predictive Value vs. Skin Prick Testing (SPT)* *Adapted from Reference 1. †CAP RAST Specific IgE blood test was used in this study. 1. Wood RA, et al. J Allergy Clin Immunol. 1999;103:733-779. CAP RAST Authors concluded that CAP RAST Specific IgE blood test and SPT values both exhibited excellent efficiency1 CAP RAST® Return to previous slide Profiles Carefully Designed Profiles engineered to detect >95% of patients with allergy1-3 Regional respiratory profiles include key indoor/outdoor allergens selected according to: Geographic pollen patterns Regional disease prevalence Cross reactivity to other allergens in each inhalant class Allergy March profiles include key food/inhalant allergens Six foods account for 90% of food allergy reactions in children4 Inhalants include common/cross-reactive indoor and outdoor allergens Generally recommended for children ≤6 years of age, based on symptoms CAP RAST Sampson HA, Ho DG. J Allergy Clin Immunol. 1997;100:444-451. Yunginger JW, et al. J Allergy Clin Immunol. 2000;105:1077-1084. Poon AW, et al. Am J Man Care. 1998;4:969-985. AAAAI. The Allergy Report. 2000;3:69. CAP RAST® Understanding Total IgE1 Total IgE often of little practical value when considered alone Levels rarely high when specific IgE titers are not Lacks sensitivity as a rule-out screen: Specific IgE levels may be significantly high when total IgE is low/normal Extremely high total IgE may be seen in some very rare non-atopic conditions2: Certain immunodeficiency diseases (including HIV) IgE myeloma Drug-induced interstitial nephritis Graft-versus-host disease Parasitic diseases Skin diseases in addition to eczema Hyper-IgE syndrome (dermatitis, recurrent pyogenic infection) CAP RAST Fromer LM. J Fam Pract. 2004;suppl:S4-S14. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Understanding Total IgE CAP RAST Return to previous slide *Includes URDs (Upper Respiratory Diseases), CHDs (Childhood Diseases), and LRDs (Lower Respiratory Diseases) 1. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Interpretation of Total IgE* Results Negative (Normal) Positive (Abnormal, Elevated) Negative (Normal) Positive (Abnormal, Elevated) Non-allergic Patient Scenario A Rare1 Scenario B Allergic Patient Scenario C Allergic Patient Scenario D Specific IgE Reading Total IgE Reading Perspectives Perspectives Third-party Perspectives Childhood diseases EAACI AAP Upper respiratory diseases JCAAI (guidelines for chronic rhinitis) AAAAI – The Allergy Report AHRQ (Agency for Healthcare Research and Quality) Multiple textbooks Lower respiratory diseases NIH (asthma guidelines) AAFP (asthma guidelines) FDA (Xolair® indications) “Generally, all individuals with severe, persisting or recurrent possible ‘allergic symptoms’ and individuals with need for continuous prophylactic treatment should be tested for specific allergy regardless of the age of the child.” Høst A, et al. Allergy. 2003;58:559-569. Perspectives Perspectives Return to >> Third-party Perspectives From the European Academy of Allergy and Clinical Immunology1 AAP Pediatric Update. 2001;22:1-8. Perspectives Perspectives From the American Academy of Pediatrics1 Panel Discussion: Recent Advances in Allergy Hugh A. Sampson, MD: “The pediatrician could certainly order the blood test initially to see whether or not there were significant levels of antibody to milk, egg, or peanut in these children with atopic dermatitis….” Laurie J. Smith, MD: “It’s important to specify, however, that the only in vitro test with which such diagnostic assumptions can be made is with the CAP RAST and no other in vitro test that is available.” Return to >> Third-party Perspectives Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Perspectives Perspectives From the Joint Council of Allergy, Asthma, and Immunology1 Rhinitis should be classified by etiology as allergic or non-allergic Since approximately 50% of patients with rhinitis do not have allergic rhinitis, other potential causes must be ruled out Return to >> Third-party Perspectives Perspectives Perspectives AAAAI. The Allergy Report. 2000;1:31. From the American Academy of Allergy, Asthma & Immunology1 “Diagnostic evaluation, including specific testing, is necessary to: Confirm the allergic diagnosis Differentiate allergic disorders from other diseases Uncover previously unsuspected allergens Guide treatment” Return to >> Third-party Perspectives “Given the absence of studies to differentiate nonallergic rhinitis, diagnostic testing rather than symptoms or signs is necessary to differentiate isolated vasomotor or nonallergic rhinitis from allergic rhinitis.” AHRQ. Management of allergic and nonallergic rhinitis. May 2002. AHRQ Pub. No. 02-E023. Perspectives Perspectives From the Agency for Healthcare Research and Quality1 Return to >> Third-party Perspectives Perspectives AAFP. Asthma & Allergy Resource Guide. 2004:11-13. Perspectives From the American Academy of Family Physicians1 “Determining whether and how allergies play a role in a patient’s asthma is an important part of the clinical picture.” “Family physicians are in an ideal position to consider the full spectrum of potential allergic and non-allergic triggers in their evaluation of patients who have asthma.” “The CAP RAST serum specific immunoglobulin E (IgE) assay may also be appropriate for patients in whom skin testing is not an option….Quantitative testing…may be more useful because it identifies a patient’s specific causative allergens. CAP RAST testing is often less expensive than RAST and is a fairly simple way for family physicians to screen patients before referral to an allergist.” Return to >> Third-party Perspectives Perspectives * Xolair is a registered trademark of Genentech, Inc. and Novartis Pharmaceuticals Corporation. 1. Xolair (omalizumab) Prescribing Information. Perspectives From the U.S. Food and Drug Administration1 Indication fo omalizumab “Omalizumab is indicated for adults and adolescents (12 years of age and above) with moderate to severe asthma who have a positive skin test or in vitro reactivity to a perennial allergen and whose symptoms are inadequately controlled with inhaled corticosteroids.” Return to >> Third-party Perspectives
Slide 61 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide What Is Happening to Treatment? Mechanism of disease is better understood Means that treatments are nearer the root cause Therapeutic specificity is increasing Diseases are different and differentiation is key The mechanism of action of drugs is more specific than ever Diagnostic precision by PCP is necessary New diagnostic technology must be employed Treatment Treatment Treatment Market Review: The Role of Diagnostics in Pharmacotherapy Medications for Respiratory Allergy $$$$$$ Highly specific treatment Highly specific resolution of symptoms due to IgE response only — necessitates perfect diagnosis Binds to IgE; Suppression of IgE response Anti-IgE Vaccine (2003) $$$ Very specific to atopy — necessitates even more accurate diagnosis (Doctors report marginal response for AR with Singulair — could be 65% are not allergic) Specific resolution of symptoms of atopy by blocking another mediator pathway Leukotriene antagonist Montelukast (2002) $$ Introduction of “D” formula creates less specific treatment More specific resolution of symptoms primarily due to atopic etiology — necessitates more specific diagnosis Antihistamine effect with very little anticholinergic effect Non-sedating Antihistamines (1990s) $ Broad (shotgun) Non-specific resolution of symptoms regardless of etiology Antihistamine effect + Anticholinergic effect 1st Generation Antihistamines (1970s) Cost Therapeutic Approach Treatment Results Mode(s) of Action Treatment Progression Treatment Treatment Disease Paradigms Treatment Treatment Hx & PE lab tests diet & exercise pharmacotherapy Diabetes Mellitus Type 2 Hx & PE lipid profile diet & exercise pharmacotherapy Hypercholesterolemia Hx & PE pharmacotherapy CHDs, URDs, LRDs ? IgE profile avoidance CAP RAST: Gain Knowledge to Guide Treatment FDA-cleared quantitative measure of specific IgE Only a single blood draw required Covered under most insurance plans Accuracy superior to RASTTM*1 Next-generation assay offers consistently improved sensitivity,2 De facto standard, documented in >2,700 peer-reviewed publications3 In vitro blood testing and skin prick testing (SPT) viewed as interchangeable4 CAP RAST is available throughout the nation from all major reference and clinical laboratories, including Quest Diagnostics, NS-LIJ & BioReference * RAST is a trademark of Pharmacia Diagnostics. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. Szeinbach SL, et al. Ann Allergy Asthma Immunol. 2001;86:373-381. 3. Johansson SGO. Expert Rev Mol Diagn. 2004;4:273-279. 4. Hamilton RG. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:233-242. CAP RAST® CAP RAST® H. Drevin, 1989 A. Kober, 2004 Solid-phase Protein Binding Capacity Comparison Solid Phase CAP RAST cellulose polymer binds almost 150 times more protein than a passively coated tube, well or bead, and about 250 percent more protein than a paper disc. Accuracy of Immunoassays for Specific IgE *The authors noted that regression values below 0.80 reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. ONLY CAP RAST had consistently acceptable regression values. **Alastat was recently replaced by 3gAllergy. Studies show 93% agreement between both methods. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. CAP RAST® CAP RAST® Line represents minimum acceptable R2 performance values Alastat/ 3gAllergyTM** RAST/ Modified RAST Newest generation: CAP RAST Ideal Test (Correlation Coefficient) .65 .82 .96 - .98 1.0 Source: Williams PB, Barnes JH, Szeinbach SL, Sullivan T. Analytical precision and accuracy of commercial immunoassays for specific IgE: establishing a standard. J Allergy Clin Immunol. 2000;105(6):1221-1230. Poor Performance For Tests With R2 Below 0.80 “Given the dilution range used in this study, values of R-Square below approximately 0.80 generally reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. Only CAP RAST had consistently acceptable R-Square values, suggesting good performance in their ability to correctly detect the concentrations of specific IgE antibodies across the different samples and allergens.” Predictive Value vs. Skin Prick Testing (SPT)* *Adapted from Reference 1. †CAP RAST Specific IgE blood test was used in this study. 1. Wood RA, et al. J Allergy Clin Immunol. 1999;103:733-779. CAP RAST Authors concluded that CAP RAST Specific IgE blood test and SPT values both exhibited excellent efficiency1 CAP RAST® Return to previous slide Profiles Carefully Designed Profiles engineered to detect >95% of patients with allergy1-3 Regional respiratory profiles include key indoor/outdoor allergens selected according to: Geographic pollen patterns Regional disease prevalence Cross reactivity to other allergens in each inhalant class Allergy March profiles include key food/inhalant allergens Six foods account for 90% of food allergy reactions in children4 Inhalants include common/cross-reactive indoor and outdoor allergens Generally recommended for children ≤6 years of age, based on symptoms CAP RAST Sampson HA, Ho DG. J Allergy Clin Immunol. 1997;100:444-451. Yunginger JW, et al. J Allergy Clin Immunol. 2000;105:1077-1084. Poon AW, et al. Am J Man Care. 1998;4:969-985. AAAAI. The Allergy Report. 2000;3:69. CAP RAST® Understanding Total IgE1 Total IgE often of little practical value when considered alone Levels rarely high when specific IgE titers are not Lacks sensitivity as a rule-out screen: Specific IgE levels may be significantly high when total IgE is low/normal Extremely high total IgE may be seen in some very rare non-atopic conditions2: Certain immunodeficiency diseases (including HIV) IgE myeloma Drug-induced interstitial nephritis Graft-versus-host disease Parasitic diseases Skin diseases in addition to eczema Hyper-IgE syndrome (dermatitis, recurrent pyogenic infection) CAP RAST Fromer LM. J Fam Pract. 2004;suppl:S4-S14. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Understanding Total IgE CAP RAST Return to previous slide *Includes URDs (Upper Respiratory Diseases), CHDs (Childhood Diseases), and LRDs (Lower Respiratory Diseases) 1. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Interpretation of Total IgE* Results Negative (Normal) Positive (Abnormal, Elevated) Negative (Normal) Positive (Abnormal, Elevated) Non-allergic Patient Scenario A Rare1 Scenario B Allergic Patient Scenario C Allergic Patient Scenario D Specific IgE Reading Total IgE Reading Perspectives Perspectives Third-party Perspectives Childhood diseases EAACI AAP Upper respiratory diseases JCAAI (guidelines for chronic rhinitis) AAAAI – The Allergy Report AHRQ (Agency for Healthcare Research and Quality) Multiple textbooks Lower respiratory diseases NIH (asthma guidelines) AAFP (asthma guidelines) FDA (Xolair® indications) “Generally, all individuals with severe, persisting or recurrent possible ‘allergic symptoms’ and individuals with need for continuous prophylactic treatment should be tested for specific allergy regardless of the age of the child.” Høst A, et al. Allergy. 2003;58:559-569. Perspectives Perspectives Return to >> Third-party Perspectives From the European Academy of Allergy and Clinical Immunology1 AAP Pediatric Update. 2001;22:1-8. Perspectives Perspectives From the American Academy of Pediatrics1 Panel Discussion: Recent Advances in Allergy Hugh A. Sampson, MD: “The pediatrician could certainly order the blood test initially to see whether or not there were significant levels of antibody to milk, egg, or peanut in these children with atopic dermatitis….” Laurie J. Smith, MD: “It’s important to specify, however, that the only in vitro test with which such diagnostic assumptions can be made is with the CAP RAST and no other in vitro test that is available.” Return to >> Third-party Perspectives Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Perspectives Perspectives From the Joint Council of Allergy, Asthma, and Immunology1 Rhinitis should be classified by etiology as allergic or non-allergic Since approximately 50% of patients with rhinitis do not have allergic rhinitis, other potential causes must be ruled out Return to >> Third-party Perspectives Perspectives Perspectives AAAAI. The Allergy Report. 2000;1:31. From the American Academy of Allergy, Asthma & Immunology1 “Diagnostic evaluation, including specific testing, is necessary to: Confirm the allergic diagnosis Differentiate allergic disorders from other diseases Uncover previously unsuspected allergens Guide treatment” Return to >> Third-party Perspectives “Given the absence of studies to differentiate nonallergic rhinitis, diagnostic testing rather than symptoms or signs is necessary to differentiate isolated vasomotor or nonallergic rhinitis from allergic rhinitis.” AHRQ. Management of allergic and nonallergic rhinitis. May 2002. AHRQ Pub. No. 02-E023. Perspectives Perspectives From the Agency for Healthcare Research and Quality1 Return to >> Third-party Perspectives Perspectives AAFP. Asthma & Allergy Resource Guide. 2004:11-13. Perspectives From the American Academy of Family Physicians1 “Determining whether and how allergies play a role in a patient’s asthma is an important part of the clinical picture.” “Family physicians are in an ideal position to consider the full spectrum of potential allergic and non-allergic triggers in their evaluation of patients who have asthma.” “The CAP RAST serum specific immunoglobulin E (IgE) assay may also be appropriate for patients in whom skin testing is not an option….Quantitative testing…may be more useful because it identifies a patient’s specific causative allergens. CAP RAST testing is often less expensive than RAST and is a fairly simple way for family physicians to screen patients before referral to an allergist.” Return to >> Third-party Perspectives Perspectives * Xolair is a registered trademark of Genentech, Inc. and Novartis Pharmaceuticals Corporation. 1. Xolair (omalizumab) Prescribing Information. Perspectives From the U.S. Food and Drug Administration1 Indication fo omalizumab “Omalizumab is indicated for adults and adolescents (12 years of age and above) with moderate to severe asthma who have a positive skin test or in vitro reactivity to a perennial allergen and whose symptoms are inadequately controlled with inhaled corticosteroids.” Return to >> Third-party Perspectives Summary Diagnostic precision leads to evidence-based medical care Improves patient care Creates better patient satisfaction Provides more appropriate referrals CAP RAST Specific IgE blood test is an accurate test to differentiate atopic from non-atopic patients Experts, specialty organizations, and government agencies support allergy testing in primary care Summary Summary
Slide 62 - Allergy and Asthma: Improving Outcomes in Primary Care El Paso November, 2007 Len Fromer, M.D., FAAFP The Etiology Challenge Common symptoms and diseases have many possible etiologies IgE-mediated allergies trigger symptoms from infancy into adulthood Identification of true underlying cause is essential for effective management The Allergic Inflammatory Response Common Childhood Diseases The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma The symptoms Inflammatory in nature Multiple etiologies Treated empirically CHDs CHDs The Allergy March: A Progression of Seemingly Unrelated Diseases CHDs CHDs Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069. Allergy March CHDs CHDs Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763. Allergy March CHDs CHDs Common Childhood Diseases Atopic dermatitis (AD)1 17%-20% prevalence in US, other western countries Not necessarily severe reaction (anaphylaxis) Driven by early exposure and sensitization 40% of AD caused by food sensitivity Empirical treatment: trials of topicals CHDs Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. CHDs Common Childhood Diseases GI distress1 Colic, diarrhea, vomiting, constipation, reflux Multiple etiologies: atopy, infection, intolerance, malabsorption, inflammatory bowel, anatomic defect 10%-42% of symptomatic patients are atopic2,3 50%-60% of infants with food sensitivities show GI symptoms (not necessarily full-blown food allergy) – Empirical treatment: trials of formulas Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at: http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm. Sicherer SH. Pediatrics. 2003;111:1609-1616. CHDs CHDs Common Childhood Diseases Recurrent otitis media (OM) 26% prevalence in US1 Key risk factors include attendance in daycare, cigarette smoke exposure2 40%-50% involve atopy3,4 Common underlying cause = eustachian tube dysfunction Caused by inflammation related to allergy or infection Recurrence = not treating the underlying cause Empirical treatment: antibiotics, surgery Lanphear BP, et al. Pediatrics. 1997;99:1-7. AAAAI. The Allergy Report. 2000;2:155-161. Data on file, Pharmacia Diagnostics. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797 CHDs CHDs Atopy’s Long-Term Consequences Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1 Children with early and long-lasting food sensitization: – 3x more likely to develop allergic rhinitis (AR) than those transiently sensitized2 – 5x more likely to develop asthma than those transiently sensitized2 Young wheezers with confirmed atopy are more likely to develop asthma3 1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573. 2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67. 3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. CHDs CHDs Knowledge of Etiology Guides Treatment for Today and Tomorrow Specific IgE testing in children can help the clinician: – Identify allergen sensitivities – Counsel for avoidance – Eliminate or reduce symptoms – Reduce medication use (including antibiotics) Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5 – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1 – PAT: Immunotherapy significantly reduced asthma risk in children with AR2 – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5 ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256. Platts-Mills TAE. N Engl J Med. 2003;349:207-208. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55. CHDs CHDs Etiology Is Elusive URDs URDs Overlapping Symptoms Allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Sneezing Itchy, watery eyes Non-allergic Rhinitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Chronic Sinusitis Nasal congestion Rhinorrhea Increased secretions Postnasal drainage Headache Facial pain URDs URDs Upper Respiratory Diseases Allergic rhinitis, non-allergic rhinitis, sinusitis Symptoms caused by inflammation Multiple etiologies, including: Allergic • Hormonal Anatomic • Vasomotor Infectious Usually treated empirically/symptomatically Depending upon etiology, treatment can/should be different URDs URDs Productivity Loss $ per 1000 Employees Comparison of Quality-of-Life in Asthmatic & Chronic Rhinitis Patients Distribution of URD in US1-3 39% of total population (115M of 295M) have URD AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm. URDs 40M 35M 40M Sinusitis 30% Non-allergic Rhinitis 35% Allergic Rhinitis 35% URDs Actual Atopy and Antihistamine Use 1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238. URDs URDs Identification of allergic disease among users of antihistamines1 Allergic rhinitis, non-allergic rhinitis, sinusitis Study of managed-care patients repeatedly prescribed oral antihistamines Convenience sample of 246 evaluated with in vitro allergy testing Results revealed non-atopic symptom etiology in 2/3 of patients 35% Atopic Etiology 65% Non-atopic Etiology Non-allergic Rhinitis Wide array of types and etiologies1,2 Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced Not caused by IgE-mediated allergic inflammation Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. URDs URDs URDs Non-allergic Rhinitis: Many Possible Etiologies URDs Return to previous slide Allergic Rhinitis Triggered by seasonal or perennial allergen(s) Symptoms may include: nasal congestion, rhinorrhea, increased secretions, sneezing, itchy nose/eyes, watery eyes, coughing, postnasal drip1,2 Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded AAAAI. The Allergy Report. 2000;2:1-31. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01. Wickman M. Allergy. 2005;60 (Suppl 79):14-18. URDs URDs Cumulative Threshold Disease1 1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01. 2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979. 3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026. URDs Symptoms Situation A2 No avoidance measures Situation B3 No avoidance measures Third allergen Situation C3 Avoidance measures employed Third allergen URDs Support for Avoidance in the Management of Allergies and Asthma …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al. “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al. The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5 1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17. 2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 . 3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. 4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13 Return to >> Cumulative Threshold URDs URDs Sinusitis Multiple etiologies Caused by inflammation from infection, allergy, structural abnormalities, other causes1 ENT experts use term “rhinosinusitis” due to epithelial continuum of sinus/nasal passages1,2 Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic rhinosinusitis3 Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. AAAAI. The Allergy Report. 2000;2:7,137-153. URDs URDs Why Should You Test? History and physical alone yield a correct diagnosis only 50% of the time1 Different etiologies demand different treatment approaches Testing for specific IgE levels can rule in/out atopy If atopic: – NSAs probably drug of choice – Testing can help clinician pinpoint offending allergens If non-atopic: – Results will allow you to focus on other etiologies – Drugs of choice may include decongestants/steroids – Patient can avoid unnecessary/ineffective treatment URDs 1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031. URD Management Options Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Allergy-Targeted Pharmacotherapy (eg, NSAs, LTRAs) Stop Inadequate Response Referral? Inadequate Response URDs Specific IgE-Negative/Normal Non-Atopic Etiology Adequate Response Pharmacotherapy (allergy-targeted Rx not helpful) Stop Inadequate Response Referral? The Experts on Differential Diagnosis of Rhinitis “A positive diagnosis (or diagnoses) should be made before formulating management.”1 Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007. URDs URDs The Experts on Differential Diagnosis of Rhinitis An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians. According to these experts, in vitro tests1: Offer a well standardized alternative to skin testing Are easily used by generalist physicians Are effective in the diagnosis of allergy URDs 1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412. The Experts on Differential Diagnosis of Rhinitis “Allergy [IgE] testing should be considered in all patients with a suspected diagnosis of allergic rhinitis.”1 Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404. URDs URDs Etiology Linked to Triggers LRDs LRDs Overlapping Symptoms “All that wheezes is not asthma.” – Chevalier Jackson [1865-1958] LRDs Allergic Asthma Wheezing Cough Dyspnea Chest tightness Rhinitis Conjunctivitis Non-allergic Asthma Wheezing Cough Dyspnea Chest tightness “Bronchitis” Wheezing Cough Dyspnea LRDs Lower Respiratory Diseases Course and severity affected by inflammation (often caused by allergy) Underlying atopy shown to increase symptoms and precipitate exacerbations A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather LRDs LRDs Asthma Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2 Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3 90% of children with asthma also have allergies4 LRDs NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. HØst A, Halken S. Allergy. 2000;55:600-608. LRDs The “One Airway” Concept Common inflammatory process links upper and lower airways1 Asthma and allergic rhinitis commonly co-exist2,3 In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4 Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. Halpern MT, et al. J Asthma. 2004;41:117-126. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. AAFP. Asthma & Allergy Resource Guide. 2004:18. AAAAI. The Allergy Report. 2000;2:33,54. LRDs NIH Asthma Guidelines1 Trigger identification/control is primary management step “For at least those patients with persistent asthma on daily medications, the clinician should: Identify allergen exposures Use the patient’s history to assess sensitivity to seasonal allergens Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens Assess the significance of positive tests in context of the patient’s medical history” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051. LRDs NIH Asthma Guidelines1 (cont’d) “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.” Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.” For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.” LRDs NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051. LRDs Return to >> Third-party Perspectives Knowledge of Symptom Triggers Guides Management Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1 In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control of severity and comorbid AR In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053. LRDs LRDs Asthma Management Options LRDs Specific IgE-Negative/Normal Non-Atopic Etiology Referral? Inadequate Response Adequate Response Pharmacotherapy Allergy Rx not helpful Controller(s) Rescue Rx Stop Focus on Non-allergic Triggers Specific IgE-Positive/Abnormal Atopic Etiology Specific Allergen Avoidance Adequate Response Pharmacotherapy Treat AR (eg, NSAs) LTRAs Controller(s) Rescue Rx Stop Inadequate Response Referral? Inadequate Response “Bronchitis” Generally acute or chronic The catchall diagnosis when symptom etiology is unclear1 Chronic cough: a key symptom associated with2,3: Postnasal drip (due to rhinitis, allergic rhinitis, or sinusitis) GERD Cough-variant asthma (documented as leading cause in children4) In children: atopy is the most important risk factor for wheezing, diminished lung function, and asthma5 Empirical treatment: antibiotics, bronchodilators Hueston WJ, Mainous AG. Am Fam Physician. 1998;57:1270-1276. Lawler WR. Am Fam Physician. 1998;58(9):2015-2022. Irwin RS, Madison JM. Am J Respir Crit Care Med. 2002;165:1469-74.. Holinger LD, Sanders AD. Laryngoscope. 1991;101:596-605. Martinez FD, Godfrey S. Wheezing Disorders in the Preschool Child. Martin Dunitz; 2003:2-35. LRDs LRDs Wheezing, Atopy, and Asthma LRDs LRDs Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174. Return to previous slide What Is Happening to Treatment? Mechanism of disease is better understood Means that treatments are nearer the root cause Therapeutic specificity is increasing Diseases are different and differentiation is key The mechanism of action of drugs is more specific than ever Diagnostic precision by PCP is necessary New diagnostic technology must be employed Treatment Treatment Treatment Market Review: The Role of Diagnostics in Pharmacotherapy Medications for Respiratory Allergy $$$$$$ Highly specific treatment Highly specific resolution of symptoms due to IgE response only — necessitates perfect diagnosis Binds to IgE; Suppression of IgE response Anti-IgE Vaccine (2003) $$$ Very specific to atopy — necessitates even more accurate diagnosis (Doctors report marginal response for AR with Singulair — could be 65% are not allergic) Specific resolution of symptoms of atopy by blocking another mediator pathway Leukotriene antagonist Montelukast (2002) $$ Introduction of “D” formula creates less specific treatment More specific resolution of symptoms primarily due to atopic etiology — necessitates more specific diagnosis Antihistamine effect with very little anticholinergic effect Non-sedating Antihistamines (1990s) $ Broad (shotgun) Non-specific resolution of symptoms regardless of etiology Antihistamine effect + Anticholinergic effect 1st Generation Antihistamines (1970s) Cost Therapeutic Approach Treatment Results Mode(s) of Action Treatment Progression Treatment Treatment Disease Paradigms Treatment Treatment Hx & PE lab tests diet & exercise pharmacotherapy Diabetes Mellitus Type 2 Hx & PE lipid profile diet & exercise pharmacotherapy Hypercholesterolemia Hx & PE pharmacotherapy CHDs, URDs, LRDs ? IgE profile avoidance CAP RAST: Gain Knowledge to Guide Treatment FDA-cleared quantitative measure of specific IgE Only a single blood draw required Covered under most insurance plans Accuracy superior to RASTTM*1 Next-generation assay offers consistently improved sensitivity,2 De facto standard, documented in >2,700 peer-reviewed publications3 In vitro blood testing and skin prick testing (SPT) viewed as interchangeable4 CAP RAST is available throughout the nation from all major reference and clinical laboratories, including Quest Diagnostics, NS-LIJ & BioReference * RAST is a trademark of Pharmacia Diagnostics. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. Szeinbach SL, et al. Ann Allergy Asthma Immunol. 2001;86:373-381. 3. Johansson SGO. Expert Rev Mol Diagn. 2004;4:273-279. 4. Hamilton RG. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:233-242. CAP RAST® CAP RAST® H. Drevin, 1989 A. Kober, 2004 Solid-phase Protein Binding Capacity Comparison Solid Phase CAP RAST cellulose polymer binds almost 150 times more protein than a passively coated tube, well or bead, and about 250 percent more protein than a paper disc. Accuracy of Immunoassays for Specific IgE *The authors noted that regression values below 0.80 reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. ONLY CAP RAST had consistently acceptable regression values. **Alastat was recently replaced by 3gAllergy. Studies show 93% agreement between both methods. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230. CAP RAST® CAP RAST® Line represents minimum acceptable R2 performance values Alastat/ 3gAllergyTM** RAST/ Modified RAST Newest generation: CAP RAST Ideal Test (Correlation Coefficient) .65 .82 .96 - .98 1.0 Source: Williams PB, Barnes JH, Szeinbach SL, Sullivan T. Analytical precision and accuracy of commercial immunoassays for specific IgE: establishing a standard. J Allergy Clin Immunol. 2000;105(6):1221-1230. Poor Performance For Tests With R2 Below 0.80 “Given the dilution range used in this study, values of R-Square below approximately 0.80 generally reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. Only CAP RAST had consistently acceptable R-Square values, suggesting good performance in their ability to correctly detect the concentrations of specific IgE antibodies across the different samples and allergens.” Predictive Value vs. Skin Prick Testing (SPT)* *Adapted from Reference 1. †CAP RAST Specific IgE blood test was used in this study. 1. Wood RA, et al. J Allergy Clin Immunol. 1999;103:733-779. CAP RAST Authors concluded that CAP RAST Specific IgE blood test and SPT values both exhibited excellent efficiency1 CAP RAST® Return to previous slide Profiles Carefully Designed Profiles engineered to detect >95% of patients with allergy1-3 Regional respiratory profiles include key indoor/outdoor allergens selected according to: Geographic pollen patterns Regional disease prevalence Cross reactivity to other allergens in each inhalant class Allergy March profiles include key food/inhalant allergens Six foods account for 90% of food allergy reactions in children4 Inhalants include common/cross-reactive indoor and outdoor allergens Generally recommended for children ≤6 years of age, based on symptoms CAP RAST Sampson HA, Ho DG. J Allergy Clin Immunol. 1997;100:444-451. Yunginger JW, et al. J Allergy Clin Immunol. 2000;105:1077-1084. Poon AW, et al. Am J Man Care. 1998;4:969-985. AAAAI. The Allergy Report. 2000;3:69. CAP RAST® Understanding Total IgE1 Total IgE often of little practical value when considered alone Levels rarely high when specific IgE titers are not Lacks sensitivity as a rule-out screen: Specific IgE levels may be significantly high when total IgE is low/normal Extremely high total IgE may be seen in some very rare non-atopic conditions2: Certain immunodeficiency diseases (including HIV) IgE myeloma Drug-induced interstitial nephritis Graft-versus-host disease Parasitic diseases Skin diseases in addition to eczema Hyper-IgE syndrome (dermatitis, recurrent pyogenic infection) CAP RAST Fromer LM. J Fam Pract. 2004;suppl:S4-S14. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Understanding Total IgE CAP RAST Return to previous slide *Includes URDs (Upper Respiratory Diseases), CHDs (Childhood Diseases), and LRDs (Lower Respiratory Diseases) 1. AAAAI. The Allergy Report. 2000;1:35. CAP RAST® Interpretation of Total IgE* Results Negative (Normal) Positive (Abnormal, Elevated) Negative (Normal) Positive (Abnormal, Elevated) Non-allergic Patient Scenario A Rare1 Scenario B Allergic Patient Scenario C Allergic Patient Scenario D Specific IgE Reading Total IgE Reading Perspectives Perspectives Third-party Perspectives Childhood diseases EAACI AAP Upper respiratory diseases JCAAI (guidelines for chronic rhinitis) AAAAI – The Allergy Report AHRQ (Agency for Healthcare Research and Quality) Multiple textbooks Lower respiratory diseases NIH (asthma guidelines) AAFP (asthma guidelines) FDA (Xolair® indications) “Generally, all individuals with severe, persisting or recurrent possible ‘allergic symptoms’ and individuals with need for continuous prophylactic treatment should be tested for specific allergy regardless of the age of the child.” Høst A, et al. Allergy. 2003;58:559-569. Perspectives Perspectives Return to >> Third-party Perspectives From the European Academy of Allergy and Clinical Immunology1 AAP Pediatric Update. 2001;22:1-8. Perspectives Perspectives From the American Academy of Pediatrics1 Panel Discussion: Recent Advances in Allergy Hugh A. Sampson, MD: “The pediatrician could certainly order the blood test initially to see whether or not there were significant levels of antibody to milk, egg, or peanut in these children with atopic dermatitis….” Laurie J. Smith, MD: “It’s important to specify, however, that the only in vitro test with which such diagnostic assumptions can be made is with the CAP RAST and no other in vitro test that is available.” Return to >> Third-party Perspectives Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. Perspectives Perspectives From the Joint Council of Allergy, Asthma, and Immunology1 Rhinitis should be classified by etiology as allergic or non-allergic Since approximately 50% of patients with rhinitis do not have allergic rhinitis, other potential causes must be ruled out Return to >> Third-party Perspectives Perspectives Perspectives AAAAI. The Allergy Report. 2000;1:31. From the American Academy of Allergy, Asthma & Immunology1 “Diagnostic evaluation, including specific testing, is necessary to: Confirm the allergic diagnosis Differentiate allergic disorders from other diseases Uncover previously unsuspected allergens Guide treatment” Return to >> Third-party Perspectives “Given the absence of studies to differentiate nonallergic rhinitis, diagnostic testing rather than symptoms or signs is necessary to differentiate isolated vasomotor or nonallergic rhinitis from allergic rhinitis.” AHRQ. Management of allergic and nonallergic rhinitis. May 2002. AHRQ Pub. No. 02-E023. Perspectives Perspectives From the Agency for Healthcare Research and Quality1 Return to >> Third-party Perspectives Perspectives AAFP. Asthma & Allergy Resource Guide. 2004:11-13. Perspectives From the American Academy of Family Physicians1 “Determining whether and how allergies play a role in a patient’s asthma is an important part of the clinical picture.” “Family physicians are in an ideal position to consider the full spectrum of potential allergic and non-allergic triggers in their evaluation of patients who have asthma.” “The CAP RAST serum specific immunoglobulin E (IgE) assay may also be appropriate for patients in whom skin testing is not an option….Quantitative testing…may be more useful because it identifies a patient’s specific causative allergens. CAP RAST testing is often less expensive than RAST and is a fairly simple way for family physicians to screen patients before referral to an allergist.” Return to >> Third-party Perspectives Perspectives * Xolair is a registered trademark of Genentech, Inc. and Novartis Pharmaceuticals Corporation. 1. Xolair (omalizumab) Prescribing Information. Perspectives From the U.S. Food and Drug Administration1 Indication fo omalizumab “Omalizumab is indicated for adults and adolescents (12 years of age and above) with moderate to severe asthma who have a positive skin test or in vitro reactivity to a perennial allergen and whose symptoms are inadequately controlled with inhaled corticosteroids.” Return to >> Third-party Perspectives Summary Diagnostic precision leads to evidence-based medical care Improves patient care Creates better patient satisfaction Provides more appropriate referrals CAP RAST Specific IgE blood test is an accurate test to differentiate atopic from non-atopic patients Experts, specialty organizations, and government agencies support allergy testing in primary care Summary Summary URD Inhalant Panel Interpretation Of Results