Allergy & Immunology
Expert discussions on allergic conditions, immunodeficiencies, drug hypersensitivity, and immunotherapy approaches.
Recent Discussions
Is there a role for omalizumab in a patient who is on VIT but still experiences anaphylaxis to stinging insects?
The Practice Parameters suggest that the dose should be doubled in such patients for improved protection, so omalizumab may not be the first step. Also, the frequency of the maintenance dose could be increased (e.g. every 2-3 weeks). Although there may be a role for omalizumab (off-label) to reduce ...
How do you recommend spacing dosing between immunoglobulin replacement and eculizmab administration?
I know of no direct data on this point. PK studies of IVIg would suggest that competition for FcRn would reduce Eculizumab levels right after an IVIG infusion, so it might be best to give the Eculizumab 10-14 days after the IVIG, when the peak of IVIG has passed. Levine suggests transitioning from I...
How do you approach treatment for a patient with T2N0, ER+/PR+, HER2 negative breast cancer with planned TC treatment following a hypersensitivity reaction?
We don't have a trial with albumin bound paclitaxel plus cyclophosphamide vs. TC to guide you here. There is also some conflicting guidance on managing Docetaxel hypersensitivity. On one hand, some references say to rechallenge with Docetaxel is contraindicated (Lenz, PMID 17522249), but if you look...
How do you treat post-IVIG headache that is not responsive to Tylenol or NSAIDs?
In my opinion, there is no one simple treatment for such headaches. We try slowing the infusion rate, premedicate with steroids, low dose Lasix, or premedicate with Nurtec. Usually, one of these methods helps minimize or eliminate the headaches.
What is your approach to working up diarrhea in an immunocompromised patient?
Tough question and very common in clinical and research management. The approach is going to mirror any new complaint and start with a history. Diarrhea means many things to many patients/clinical trial subjects, so characterizing duration, frequency in a day, nocturnal events (diarrhea that occurs ...
Do you diagnose obstruction by the criteria of FEV1/FVC < 70% or < LLN?
Using lower limit of normal for FEV1/FVC ratio may reduce misclassification of airway obstruction but despite years of discussion and arguments it remains unclear whether it is a better approach. The simplicity of the fixed ratio approach to me remains a very important consideration and it is the ap...
What is your approach to inhaler therapy in a patient with asthma who cannot be on an inhaled corticosteroid due to ocular disease?
I use LABA/LAMA combination.
Are there any special considerations when evaluating patients with non-malignant hematologic or immunodeficiency disorders for allogeneic transplant?
In most malignant diseases, we prefer to take patients to allogenic transplant either in complete or partial remission as it will take few months before post-transplant immune-reconstitution results in effective graft-versus-disease response. In non-malignant diseases, we take patients to transplant...
How does your treatment algorithm differ for drug-induced ANCA vasculitis compared to non drug-induced ANCA vasculitis in cases with severe/organ-threatening manifestations?
When end-organ manifestations are present, my initial treatment approach is similar for drug-induced and non-drug induced AAV and typically consists of glucocorticoids and rituximab, including pulse glucocorticoids with severe end-organ involvement. Common drug culprits such as PTU, hydralazine, min...
How does a history of splenectomy alter how you counsel patients on the infection risk of TNF inhibitors or other biologics?
In general, a history of splenectomy would lead to an increased concern regarding infections with parasitemia and encapsulated organisms (particularly Strep. pneumoniae, Haemophilus influenzae type b, and Neisseria meningitides). However, I would not consider prior splenectomy an absolute contraindi...