When to refer your patient to an allergist/immunologist

1. When to refer your patient to an allergist/immunologist

2. How the Allergist/Immunologist Can Help:Consultation and Referral Guidelines Citing the Evidence

3. Background • Allergic diseases affect more than • 56,000,000 Americans • There are only 5400 Board-Certified • Allergist-Immunologists in the country, but • their services are often underused • Allergist-immunologist care improves • outcomes, and optimal use of their services • should improve the public health

4. Purpose: How the Allergist/Immunologist Can Help: Consultation and Referral Guidelines Citing the Evidence was designed to assist patients and health care professionals in determining when referral to an allergist/immunologist is needed.

5. What is an allergist/immunologist? An allergist/immunologist is a physician certified in either internal medicine or pediatrics, who has completed an additional two years of training in allergy and immunology at an accredited training program and passed the examination given by the American Board of Allergy and Immunology (ABAI).

6. The allergist/immunologist is uniquely trained in: • Allergy testing (skin, in-vitro) • History-allergy test correlation • Bronchoprovocation testing (e.g. exercise, methacholine) • Environmental control instructions • Inhalant immunotherapy • Immunomodulator therapy (e.g. anti-IgE, IVIG) • Venom immunotherapy • Food and drug challenges • Drug desensitization • Evaluation of immune competence • Education (disease, medications, monitoring) • Management of chronic or recurrent conditions where allergy is not always identified: rhinosinusitis, conjunctivitis, asthma, cough, urticaria/angioedema, eczema, anaphylaxis

7. Types of Evidence Used For These Guidelines • Diagnostic: Tests performed or interpreted by • allergist-immunologists facilitate diagnosis • Direct outcome evidence: Evidence that • intervention by an allergist-immunologist improves • outcomes • Indirect outcome evidence: Evidence that • interventions performed by allergist-immunologists • improve outcomes

8. How the Allergist/Immunologist Can Help:Consultation and Referral Guidelines Citing the Evidence • Urticaria/Angioedema • Who to refer to an allergist/immunologist: • Patients with chronic urticaria or angioedema, i.e..those with lesions recurring persistently over a period of six weeks or more. • Patients who may have urticarial vasculitis or urticaria with systemic disease (vasculidities, connective tissue disease, rarely malignancies).Why an allergist/immunologist: • Allergist/immunologist training and expertise should allow appropriate differential diagnosis, determination of the need for biopsy, elimination of a specific inciting agent and optimal pharmacotherapy.

9. How the Allergist/Immunologist Can Help:Consultation and Referral Guidelines Citing the Evidence • Occupational Asthma • Who to refer to an allergist/immunologist: • Patients with a history suggesting occupational asthma should undergo testing to confirm the diagnosis of asthma and referral to an allergist/immunologist for evaluation to establish that the asthma is caused by or triggered by agents at the workplace and to initiate appropriate avoidance therapy. • Why an allergist/immunologist: • Allergist/immunologists can outline an algorithm for the clinical investigation of suspected occupational asthma. Allergists can arrange and interpret studies to confirm bronchial hyperresponsiveness and workplace challenges.

10. How the Allergist/Immunologist Can Help:Consultation and Referral Guidelines Citing the Evidence • Rhinitis • Who to refer to an allergist/immunologist: • Patients with prolonged or severe manifestations of rhinitis with co-morbid conditions (e.g. asthma, recurrent sinusitis, nasal polyps); with symptoms interfering with quality of life and/or ability to function; or who have found medications to be ineffective or have had adverse reactions to medications. • Why an allergist/immunologist: • Allergist/immunologist care for rhinitis is associated with improved quality of life, compliance and satisfaction with care. • Allergist/immunologists have familiarity with the wide variety of both indoor and outdoor aeroallergen exposures that have been shown to impact on the upper respiratory tree and have the expertise to provide avoidance education and immunotherapy when indicated. • Allergist/immunologists are specifically trained and experienced in the medical management of nasal polyps, including intranasal steroids, oral steroids • and treatment of complication sinusitis.

11. How the Allergist/Immunologist Can Help:Consultation and Referral Guidelines Citing the Evidence • Food Allergy • Who to refer to an allergist/immunologist: • Persons who have limited their diet based upon perceived adverse reactions to foods or additives. • Persons who have experienced allergic symptoms (urticaria, angioedema, itch, wheezing, gastrointestinal responses) in association with food exposure. • Why an allergist/immunologist: • Following allergy evaluation, an estimated one third of perceived adverse reactions to foods and a small fraction of adverse reactions to additives are verified. • Evaluation by an allergist/immunologist is likely to result in an individual’s ability to liberalize their diet (thereby likely improving nutrition and quality of life). • The allergist/immunologist can perform diagnostic tests such as skin tests, serum IgE tests and oral food challenges to determine the cause of • the reaction so that necessary avoidance can be instituted.

12. How the Allergist/Immunologist Can Help:Consultation and Referral Guidelines Citing the Evidence • Anaphylaxis • Who to refer to an allergist/immunologist: • Individuals with a severe allergic reaction (anaphylaxis) without an obvious or previously defined trigger. • Persons with anaphylaxis attributed to food or drugs. • Why an allergist/immunologist: • After a severe allergic reaction without a known cause, a trigger should be identified if at all possible. Suspected food and drug allergy should be confirmed if possible so that necessary avoidance can be instituted. An allergist/immunologist is the most appropriate medical professional to perform this evaluation, which may include • skin testing, in vitro tests and challenges when indicated.

13. How the Allergist/Immunologist Can Help:Consultation and Referral Guidelines Citing the Evidence • Insect Hypersensitivity • When to refer to an allergist/immunologist: • Consider referral of patients with systemic reactions suspected or possibly due to insect for accurate identification of specific allergen and consideration for venom immunotherapy (or whole body extract in case of fire ant). • Why an allergist/immunologist: • Allergy testing and history-test correlation can more accurately identify specific insects responsible for an allergic reaction and may be helpful in diagnosis, treatment and avoidance recommendations. • Skin testing is generally preferred over in vitro testing for the initial evaluation of venom-specific IgE antibodies. • Venom immunotherapy (or fire ant whole body extract) greatly reduces the risk of systemic reactions in stringing insect-sensitive patients.

14. How the Allergist/Immunologist Can Help: • Consultation and Referral Guidelines Citing the Evidence • Asthma Treatment: Adherence • Who to refer to an allergist/immunologist: • Patients with asthma in whom adherence problems may be limiting optimal control. • Why an allergist/immunologist: • Patients who have visited an allergist/immunologist in the prior year were significantly more likely to have been dispensed an optimally effective number of inhaled steroid canisters. • Specialty care is associated with more refills of anti-inflammatory medications. • After visiting an allergist/immunologist, patient compliance with national asthma guidelines was higher

15. How the Allergist/Immunologist Can Help:Consultation and Referral Guidelines Citing the Evidence • Asthma Diagnosis • Who to refer to an allergist/immunologist: • Patients with respiratory symptoms suggestive of asthma but with normal PFT and no significant reversibility. • Exercise-induced symptoms that are atypical or do not respond well to pre-treatment with albuterol. • Why an allergist/immunologist: • Allergist/immunologists perform methacholine challenges, which have a high sensitivity for current asthma. • Further objective evaluation and confirmation with pulmonary function testing (including exercise challenge) in conjunction with appropriate allergist/immunologist evaluation will define diagnosis or differential diagnosis.

16. How the Allergist/Immunologist Can Help:Consultation and Referral Guidelines Citing the Evidence • Allergic bronchopulmonary aspergilllosis (ABPA) • Who to refer to an allergist/immunologist: • Patients with suspected/proven asthma or cystic fibrosis who have pulmonary infiltrates and peripheral blood eosinophilia. • Patients with known ABPA for management. • Why an allergist/immunologist: • Allergen skin testing and in vitro tests, when correlated with history, can establish the diagnosis of ABPA • Allergist/immunologists are specifically trained to manage this disease, and positive outcomes of such management have been reported by allergist/immunologists.

17. How the Allergist/Immunologist Can Help:Consultation and Referral Guidelines Citing the Evidence • Primary Immune Deficiency • Who to refer to an allergist/immunologist: • Patients with any of the following warning signs: • Frequent or severe infections (8 total or 2 serious) • Two or more months on antibiotic with little or no effect or need for IV • antibiotics to clear infections. • Failure of an infant to gain weight or grow normally • Persistent thrush in mouth or elsewhere on skin • Family history of immune deficiency. • Why an allergist/immunologist: • Allergist/immunologists are trained to diagnose and treat primary immunodeficiency. Immunologic therapy reduces infections, prevents complications and improves the quality of life in patients with primary immune deficiencies.

18. How the Allergist/Immunologist Can Help:Consultation and Referral Guidelines Citing the Evidence • Drug Allergy • Who to refer to an allergist/immunologist: • Patients with a history of penicillin allergy who have a significant probability of requiring future antibiotic therapy or have an infection in which a penicillin-class antibiotic is the drug of choice. • Patients with histories of multiple drug allergy/intolerance. • Patients with a history of possible allergic reactions to biotherapeutics, NSAIDS, chemotherapy medications, local anesthetics, or other drugs they may need. • Why an allergist/immunologist: • Allergist/immunologists provide a comprehensive plan to evaluate the historical adverse drug reactions and provide suggestions on future therapies to minimize risks. • Allergist/immunologists perform skin testing using appropriate concentrations and techniques to determine current sensitivity • Allergist/immunologists perform desensitization and • incremental drug challenges when necessary

19. How the Allergist/Immunologist Can Help:Consultation and Referral Guidelines Citing the Evidence • Asthma Treatment: Immunotherapy • Who to refer to an allergist/immunologist: • There is a clear relationship between asthma and exposure to an unavoidable aeroallergen to which specific IgE antibodies have been demonstrated and any of the following: • Poor response to pharmacotherapy or avoidance measures • Unacceptable side effects of medications • Desire to avoid long-term pharmacotherapy . • Coexisting allergic rhinitis. • Why an allergist/immunologist: • The efficacy of immunotherapy for allergic asthma has been demonstrated in many studies. Immunotherapy may also prevent the development of new allergen sensitivities.

20. How the Allergist/Immunologist Can Help:Consultation and Referral Guidelines Citing the Evidence • Asthma Treatment: Prevention of Morbidity • Who to refer to an allergist/immunologist: • Patients with uncontrolled asthma. • Patients who use excessive amounts of reliever medications • Patients with who require emergency department care for asthma. • Patients with moderate or severe persistent asthma. • Why an allergist/immunologist: • Allergist/immunologist care reduces subsequent asthma emergency department visits, hospitalizations, asthma symptoms, overuse of short acting beta agonists and cost of care for asthma. • Allergist/immunologist care improves physical functioning and asthma related quality of life. • Allergist/immunologist care results in improved patient self-management

21. How the Allergist/Immunologist Can Help:Consultation and Referral Guidelines Citing the Evidence • Asthma: Environmental diagnosis and management • Who to refer to an allergist/immunologist: • Patients with a history of seasonal or persistent asthma for evaluation of inhalant sensitization. • Patients who need management and education concerning environmental triggers. • Why an allergist/immunologist: • Exposure to indoor and outdoor allergens may worsen asthma. Allergist/immunologists have familiarity with the wide variety of both indoor and outdoor aeroallergen exposures that have been shown to impact on asthma and respiratory function. Allergist/immunologists are specifically trained to identify relevant environmental triggers and provide education regarding appropriate avoidance measures. Allergen avoidance can improve asthma.

22. How the Allergist/Immunologist Can Help:Consultation and Referral Guidelines Citing the Evidence • Asthma: Preventing mortality • Who to refer to an allergist/immunologist: • Patients with potentially fatal asthma (prior severe, life threatening episode or prior intubation). • Why an allergist/immunologist: • Allergist/Immunologists prescribe inhaled and oral steroids more frequently than primary care physicians, and these medications reduce the risk of fatal asthma. • Allergist/Immunologists perform objective measures of pulmonary function more frequently than other physicians, and this may identify “poor perceivers” who are at risk of dying from asthma • Allergist/immunologists are more likely to provide action plans to their patients, and action plans can reduce asthma mortality

23. How the Allergist/Immunologist Can Help:Consultation and Referral Guidelines Citing the Evidence • Conjunctivitis • Who to refer to an allergist/immunologist: • Patients with prolonged or recurrent manifestations of allergic conjunctivitis. • Patients with co-morbid conditions such as asthma, rhinitis or recurrent sinusitis. • Patients with symptoms interfering with quality of life and/or ability to function. • Patients who have found medications to be ineffective or have had adverse reactions to previously prescribed medications. • Why an allergist/immunologist: • Allergy cannot be diagnosed on the basis of history alone. Diagnosis is derived from a correlation of clinical history and diagnostic tests, with which allergist/immunologists are experienced. Allergist/Immunologists can provide environmental control advice and immunotherapy that can lead to reduced symptoms and need for medications

24. How the Allergist/Immunologist Can Help:Consultation and Referral Guidelines Citing the Evidence • Cough • Who to refer to an allergist/immunologist: • Patients with chronic cough of 3-8 weeks or more. • Patients with coexisting chronic cough and asthma. • Patients with coexisting chronic cough and rhinitis. • Patients with chronic cough and tobacco use or exposure. • Why an allergist/immunologist: • Allergist/immunologists have extensive training to evaluate the upper as well as lower airway in a patient with chronic cough. • The allergist/immunologist can both provide expert consultation to ensure the diagnosis of asthma is correct and maximize therapy in the asthmatic patient. • Allergist/immunologists are specifically trained and experienced in the management of rhinitis which can cause cough.

25. How the Allergist/Immunologist Can Help:Consultation and Referral Guidelines Citing the Evidence • Atopic Dermatitis • Who to refer to an allergist/immunologist: • To confirm the diagnosis of atopic dermatitis in a patient with dermatitis. • To identify the role of dust mite allergy in patients with atopic dermatitis. • To identify the role of food allergy in patients with atopic dermatitis. • Patients whose atopic dermatitis responds poorly to treatment. • Why an allergist/immunologist: • Defining IgE-mediated sensitivity (by skin or in vitro testing) is useful in the differential diagnosis. • Avoidance of relevant mite or food allergens improves atopic dermatitis • Allergist/immunologists are specifically trained and experienced in managing atopic dermatitis in both children and adults.

26. How the Allergist/Immunologist Can Help:Consultation and Referral Guidelines Citing the Evidence • Contact Dermatitis • Who to refer to an allergist/immunologist: • To confirm the diagnosis of contact dermatitis and identify the etiology. • Why an allergist/immunologist: • Allergist/immunologists are specifically trained to diagnose contact dermatitis. • More allergist/immunologists than dermatologists currently perform patch testing. • If an etiology is defined, avoidance therapy can be initiated.

27. How the Allergist/Immunologist Can Help:Consultation and Referral Guidelines Citing the Evidence • Sinusitis • Who to refer to an allergist/immunologist: • Patients with chronic or recurrent Infectious rhinosinusitis. • Patients with chronic eosinophilic rhinosinusitis. • Patients with Allergic Fungal Rhinosinusitis. • Why an allergist/immunologist: • Allergist/immunologist care is associated with improved outcomes in patients with rhinosinusitis. • Allergy immunotherapy is demonstrated to improve outcomes in patients with concomitant allergic rhinitis. • Many patients with infectious rhinosinusitis have humoral immunodeficiency, cystic fibrosis, fungal sinusitis or granulomatous diseases that allergist/immunologists are trained to identify. • Allergy testing aids in the diagnosis of Allergic Fungal • Rhinosinusitis, and immunotherapy has been reported to • improve outcomes

28. How the Allergist/Immunologist Can Help:Consultation and Referral Guidelines Citing the Evidence • Hypersensitivity Pneumonitis • Who to refer to an allergist/immunologist: • To confirm the diagnosis is suspected cases. • To rule out hypersensitivity pneumonitis in patients with interstitial pneumonitis • For management of patients with known hypersensitivity pneumonitis • Why an allergist/immunologist: • Early accurate diagnosis and removal from further exposure carries the best medical prognosis for hypersensitivity pneumonitis • .Allergist/Immunologists are specifically trained in the diagnosis of hypersensitivity pneumonitis • Allergist/Immunologists are specifically trained in the • management of hypersensitivity pneumonitis