By the end of this lecture physicians will:

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4 By the end of this lecture physicians will: 1. Be able to identify patients who need immune work-up. 2. Be able to recognize the manifestation of food allergies. 3. Be knowledgeable about alternative treatments for asthma. 4. Know when to refer patients to an allergist.

5 The five things: Immune deficiency Food allergies Asthma Allergic rhinitis Drug allergies

6 Most common immune deficiency. Manifests by recurrent bacterial infections, constant fatigue, and poor quality of life. E.g. Sinusitis, pneumonia, bronchitis. Early diagnosis results in better patient outcomes. Lab work-up includes: IgG, IgA, IgM, IgG subclasses, pneumococcal panel.

7 Not very common. Manifests by recurrent bacterial infections, persistent fungal infections, and failure to thrive. Physical exam: Child failing to thrive, tinea corporis, tinea capitis, persistent thrush and diaper rash, and no tonsilar tissue or lymph nodes.

8 Work-up includes: Chest x-ray, CBC with differentiation, IgG, IgA, IgM. If work-up confirms suspicion of immunodeficiency, refer to immunologist.

9 Oral allergy syndrome Acute urticaria Anaphylactic reaction Atopic dermatitis Migraine headache Vaccine

10 Manifests with itchy lips, mouth, and throat It is self limited. Almost always does not progress to severe reaction. Caused by allergy to fruits and vegetables. Treatment is avoidance and antihistamine medications.

11 Can be caused by food allergies. Patient needs food testing (prick or RAST) if the reaction reoccurs. Positive test to certain foods does not indicate allergy. History should correlate with the reaction. Acute Urticaria due to food allergy is more common in kids than in adults.

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13 Manifests with hives, swelling of the lips, tongue, throat, difficulty breathing, hypotension, and can be fatal. In children, 70% is food related. Patient needs food testing. Treatment includes avoiding strongly positive foods that correlate with the history of the reaction. Patient needs to carry EpiPen at all times.

14 One third of atopic dermatitis patients symptoms are triggered by food allergies. Food skin testing is needed. Treatment includes: Avoidance of positive foods. Short course of oral steroids. Topical steroids. Skin moisturizer.

15 Case: Patient J.M. was a 65yr old female who presented with daily migraine headaches for thirty five years. Her Head MRI was normal. She was treated with prophylactic meds and PRN meds without improvement. Food test results revealed positive reaction to 6 foods. Tx: Food avoidance

16 Skin Test Consumption MMR & Flu Vaccine Recommendation + No reaction Yes ++ Mild-to-moderate reaction Yes ++++ Severe reaction Only in allergist s office

17 Prick test is: Cheaper Quicker More accurate Limited RAST testing can be helpful.

18 It is an inflammatory disease. Asthma is classified as: Mild intermittent asthma Mild persistent asthma Moderate persistent asthma Severe persistent asthma

19 Mild intermittent asthma Short acting beta-agonist used on PRN basis. Mild persistent asthma Steroid inhaler on daily basis with short acting betaagonist used on PRN basis. Moderate persistent asthma Combined LABA / steroid inhaler daily with short acting beta-agonist used on PRN basis. Severe persistent asthma Combined LABA / steroid inhaler, and leukotriene receptor antagonist daily with short acting betaagonist used on PRN basis.

20 Who needs to be on Omalizumab: Asthma patients who have moderate-to-severe asthma, which is not controlled despite being on combined LABA / steroid inhaler, and leukotriene receptor antagonist daily. Patients who require frequent (every 6-8 weeks) oral steroid burst, or are on daily oral steroids. Patients with frequent ER visits. Patients with frequent hospitalization.

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22 An anti-ige antibody. Binds to IgE in the blood and on mast cells. Is administered SQ. Dose and frequency depend on IgE levels and patient weight. Patient needs to have an EpiPen handy for 24 hours after every injection.

23 Storms, W., Matthew S.B., Judith R.F., Omalizumab and asthma control in patients with moderate-to-severe allergic asthma: A 6-year pragmatic data review. Allergy Asthma Proceedings. Vol.33:2 Mar-Apr 2012.

24 National cohort study of the leukotriene receptor antagonist, montelukast, and incident or recurrent cardiovascular disease. 7 million people followed from July 2005 to December Published March 2012

25 Key results: Montelukast use resulted in lower risk for recurrent stroke. Montelukast significantly lowered the risk of recurrent myocardial infarction in male subjects. Be on the look out for future studies supporting these results.

26 Manifests with: Runny itchy nose Itchy, teary eyes Sneezing attacks Post nasal drip Constant fatigue and irritability

27 Meltzer E.O., et al. Burden of allergic rhinitis: Allergies in America, Latin America, and Asia-Pacific adult surveys. Allergy Asthma Proceedings. Vol33:5 Sept-Oct 2012.

28 Recurrent otitis media. Recurrent sinusitis Conductive Hearing loss Malocclusion Learning impairment

29 Steroid nasal spray. Oral antihistamine. Oral decongestant. Antihistamine nasal spray. Combined steroid and antihistamine nasal spray. If no response then treat with allergy immunotherapy.

30 Who needs it: Patients who are not responding to their allergy medications. Patients who can not tolerate allergy medications. Patients who need to take allergy medications year-round. Patients who want to get rid of their allergies.

31 Increases protective IgG-4 antibodies Decreases IL-4 production TH2 response Decreases IL-5 Production TH2 response Increases INF-gamma TH1 response

32 Decrease the need for allergy medications. Prevent complications. Prevent recurrent infections. Decrease the risk of developing asthma. Eliminate allergies.

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35 Meta-analysis of 36 double blind randomized controlled trials with 3014 grass-allergic patients, and 2768 control patients. Conclusion: SCIT is more effective than SLIT in controlling symptoms and reducing medication use in grass-allergic subjects.

36 Make sure it is an allergic reaction. Patient can be confused by positive prick skin test to penicillium and think they have a penicillin allergy. Penicillin test can be performed if there is no alternative antibiotic options. Desensitization can be done for certain drugs.

37 1) Fung I., Sprgel J.M.. Administration of Influenza Vaccine to Pediatric Patients with Egg Induced Anaphylaxis. JACI, 2012; 129(4): ) Neuman-Sunshine D.L., Eckmen J.A., Keet C.A. et al. The Natural History of Persistent Peanut Allergy. Ann. Allergy Asthma Immunology, 2012; 108: ) Assa ad, et al. Food Allergy: Diagnosis and Beyond. Ann. Allergy Asthma Immunology, 2012; 108: ) Ingelsson E., Yin L., Back M.. Nationwide Cohort Study of the Leukotriene Receptor Antagonist, Montelukast, and Incident or Recurrent Cardiovascular Disease. JACI, 2012; 129: ) Mary-Helen Lafeuille, et al. Impact of Omalizumab on Emergency Department Visits Hospitalizations and Corticosteroid Use Among Patients with Uncontrolled Asthma. Ann. Allergy Asthma Immunology, 2012; 109: ) Busse W., et al. Omalizumab and the Risk of Malignancy: Result from Pooled Analysis. JACI, 2012; 129: ) Chips, et al. Omalizumab: An Update on Efficacy and Safety in Moderate-to-Severe Allergic Asthma. Allergy and Asthma Proceedings, 2012; 33: ) Danilo D.I., Bona et al. Efficay of Subcutaneous and Sublingual Immunotherapy with Grass Allergens for Seasonal Allergic Rhinitis: A Meta-analysis-based Comparison. JACI, 2012; 130: ) Blanca M. Thong, B.Y.. Allergic Drug Reactions: From Basic Research to Clinical Practice. Current Opinion Allergy Clinical Immunology, 2011; 11: ) Huang F., et al. Anaphylaxis in New York City Pediatric Emergency Department Triggers, An Outcome. GACI, 2012; 129: ) Baker T., et al. The Ten Study: Time Epinephrine Needs to Reach Muscle. Ann. Allergy Asthma Immunology, 2011; 107: ) Jacobsen R.C., Guess T.M., Burks A.W.. Comparing Activation and Recoil Forces Generated by Epinephrine Auto-injectors and their Training Devices. JACI, 2012; 129(4): ) Meltzer E.O., et al. Burden of Allergic Rhinitis: Allergies in America, Latin America, and Asia-Pacific Adult Surveys. Allergy Asthma Proceedings, 2012; 33(5):S113-S ) Storms, W., Matthew S.B., Judith R.F., Omalizumab and Asthma Control in Patients with Moderate-to-Severe Allergic Asthma: A 6-year Pragmatic Data Review. Allergy Asthma Proceedings, 2012; 33(2):