Allergy & Immunology
Expert discussions on allergic conditions, immunodeficiencies, drug hypersensitivity, and immunotherapy approaches.
Recent Discussions
Do you diagnose MCAS if a patient is concurrently on drugs known to cause non-specific mast cell degranulation?
Yes, MCAS may be diagnosed if a patient is on drugs known to cause non-specific mast cell activation.The reason for this answer requires a better understanding of MCAS criteria and etiology. In 2022, an expert consortium proposed revisions to the classification of mast cell activation disorders. (Va...
Are there certain clinical features that help you choose between benralizumab and mepolizumab for EGPA in clinical practice?
Given, as noted above, no significant clinical differences between benralizumab and mepolizumab, assuming there are no specific insurance differences between the two, I preferentially prescribe benralizumab because of the 8-week dosing frequency after the first three 4-week loading doses. For a few ...
Do you scale up 2nd generation anti-histamines to 4x daily in acute urticaria in the pediatric population as you do in adults?
Severe urticaria is certainly a therapeutic challenge. Updosing 2nd generation antihistamines in children has been studied, more trials need to be done. For refractory urticaria in children, I will often recommend 2X the recommended dose of a 2nd generation antihistamine in the morning and maximize ...
When would you suspect an allergy to the dialysis membrane in patients who complain of pruritis during dialysis?
The short answer is no. Pruritus is so common with renal disease, and allergic reactions to dialyzers are uncommon. If the pruritus can confidently be documented to be only during dialysis and not at any other time, then it may be worth trying a different dialyzer but it would take a lot for me to b...
Are you increasing the dose and/or frequency of Xolair administration if patients have failed standard dosing for CSU?
The data with omalizumab is clear that updosing is safe and effective. Dupilumab, omalizumab, and remibrutinib are all about equally effective (about 60%), but updosing omalizumab to 300 every 2 weeks and even to 600 every 2 weeks gives a 60% benefit to the 40% that fail 300 a month.
Do you continue to check tryptase levels in your patients with idiopathic anaphylaxis despite normal levels >5 on repeated checks?
Baseline serum tryptase levels have been reported to be quite stable in the vast majority of patients, but can vary more in people with HaT or mastocytosis. With a bST <8 ng/ml, there is no obvious reason to continue to check it. However, even with normal bST, the Practice Parameters recommend furth...
What VIT would you recommend in a patient who had grade 5 anaphylaxis to a stinging insect but negative IDT and serum IgE?
The short answer is none. Venom immunotherapy (VIT) is absolutely dependent on demonstrating specific IgE to the suspected agent. Without specific IgE, I would not recommend starting VIT. When faced with the dilemma of post-insect sting anaphylaxis and negative skin tests(ST) and serum tests, the fi...
How do you handle hypogammaglobulinemia detected in patients prior to maintenance rituximab infusion?
That is a good question. Adding on to Dr. @Dr. First Last's response, rituximab has been shown to cause hypogammaglobulinemia that can persist or worsen with ongoing therapy. In a study published by Barmettler and colleagues, 133 patients out of a cohort of 8633 patients had serum IgG levels checked...
Are you requiring markers other than LTE4 to be elevated to diagnose MCAS?
The commercially available biomarkers to assess systemic mast cell activation in vivo include serum tryptase, N-methyl histamine (major metabolite of histamine), various forms of 11-beta-PGF2-alpha (PGD2 metabolite), and LTE4 (major metabolite of LTC4). The metabolites of these small molecules are m...
Do all patients initiating omalizumab need to have it administered in a healthcare setting?
In the trials, all cases of anaphylaxis were on first administration--suggesting it is not intrinsic to drug and is more likely because you are giving it to a group of people who may be more susceptible to anaphylaxis in general. FDA has cleared at home use, so my general approach in a patient witho...