Allergy & Immunology
Expert discussions on allergic conditions, immunodeficiencies, drug hypersensitivity, and immunotherapy approaches.
Recent Discussions
In patients with moderate persistent asthma and elevated FeNO despite adequate symptom control on omalizumab and ICS-LABA, would you consider switching to another biologic such as dupilumab or tezepelumab?
If they have adequate symptom control, not sure I would switch. If I did switch, I would. Consider Dupiumab or an anti-IL5 or IL5R blocker given the Type 2 inflammation detected by elevated FeNO.
How do you manage a delayed cutaneous reaction to docetaxel after the first cycle of adjuvant TC in early-stage HR-positive, HER2-negative breast cancer?
There is excellent guidance in the literature on management of drug-induced rashes in these patients in Sibaud et al., PMID 27550571. Management generally involves topical and if necessary systemic steroids. I particularly like using lotion versions of topical steroids such as triamcinolone as they ...
Are you performing genetic testing on all patients that you suspect to have hereditary angioedema with normal C1 inhibitor?
Yes
What is the optimal duration of biologic therapy before assessing for non-response and initiating a switch in patients with uncontrolled asthma?
I generally wait 3-6 months before changing biologic class to allow for the medications to get to a steady state. I will monitor eNO and will not wean steroids prior to 3 months.
What is the best alternative oral therapy for treatment of non-severe pulmonary nocardiosis in an immunocompetent patient with sulfa allergy?
We have been using linezolid for this indication, based on a paper from ARUP Labs.Schlaberg et al., PMID 24247124
How would you approach an asymptomatic older female patient with eosinophilia to 17,000, present for years, and normal eosinophilia workup including marrow and negative FLIP1?
Interesting case. Eos have been in the 17K range for years? Was it incidentally noted? Could just be idiopathic HES. I would worry about cardiac infiltration in an older patient, but if there have never been cardiac issues and no evidence of a myeloid variant, I would probably defer to the patient a...
With the difficulty in access to PPSV23 as the new pneumonia vaccine is now standard (non polysaccharide vaccine), have you used MPSV4 (meningococcal) vaccine for evaluation of response to polysaccharide vaccine?
No, but there is good data on using Typhim Vi vaccine, which is also polysaccharide and MCW has a good lab to evaluation for polysaccharide vaccine response.
When would you recommend prescribing an asthmatic patient budesonide/salbutamol rather than budesonide/formoterol?
This is another example of two approaches to the same issue (i.e. adding inhaled steroid to a rescue B2 adrenergic agent) which is actually more theoretical than practical since no head-to-head studies have been reported. For me, there is an intrinsic value to using a rapid onset LABA (i.e. formoter...
Do you favor 24 hour urinary metabolites over random urine collection when screening for MCAS?
In my practice, I currently use 24-hour urine metabolites. The 24-hour urine collection has been extensively validated and its use is supported by the literature (see review: Butterfield et al, PMID 35346887).That being said, a spot urine collection is now available and this is far more convenient f...
Do you cycle through topical steroids in patients with CHE, and should the approval of delgocitinib change our approach on this?
None of the topicals is effective for CHE. I have recently prescribed Anzupgo cream for a few patients, and so far results are mixed at best. What I do routinely is use intramuscular triamcinolone 80 mg, which will give a long response, and I would wait at least 8 weeks apart. Many of my patients ma...