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Slide 61 -
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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
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