Allergy & Immunology
Expert discussions on allergic conditions, immunodeficiencies, drug hypersensitivity, and immunotherapy approaches.
Recent Discussions
In those patients who are initiated on omalizumab for multiple food allergies, once baked egg and baked milk are introduced into the diet, how long should you wait until a prepared egg and whole milk challenge is conducted?
In the OuTMATCH trial, patients were on omalizumab for 16-20 weeks before undergoing food challenges, but as in every situation, the clinical history is important. Skin testing and serum IgE testing may not be reliable on omalizumab, but if the patient is tolerating and eating baked and cooked egg a...
How do you perform patch testing in patients who are allergic to adhesives?
True allergy to the Scanpor tape most often used in patch testing is rare, even in patients allergic to colophony, p-tert-butyl phenol formaldehyde resin, rubber, or acrylate-based adhesives. What is more common, especially in atopic patients with microbial dysbiosis driving their dermatitis, is fla...
Do you recommend IM Kenalog injection for refractory CRSwNP in a patient already on maximal therapy?
For refractory CRSwP on maximal therapy, IM Kenalog would not be my drug of choice. I would rather suggest Dupixent. A number of published papers including some from Klaus Bachert clearly show the benefit of Dupixent in this subgroup of patients. IM kenalog might help for a short time, but Dupixent ...
How does omalizumab play a role in the armamentarium of atopic dermatitis?
There are various reports (>30 citations) in the literature documenting Xolair efficacy in atopic dermatitis. The study designs include randomized placebo-controlled trials, retrospective case series, and case studies.A review of the literature published in 2019 by Holm & Thomsen, PMID 30717578 prov...
What are best practices in management of severe acute infusion reaction from infliximab?
Severe infusion reactions to infliximab are not typically IgE-mediated. The presumption is that it is ‘anaphylactoid’ due to IgG antibodies directed against the mouse chimeric proteins in the molecule. Stopping the infusion is essential (at least temporarily) and administering antihistamines such as...
Do you give additional pneumococcal vaccines after a dose of PCV20 in patients with asplenia?
Assuming the patient otherwise does not have immunocompromising conditions other than asplenia, following age-appropriate vaccine schedules is appropriate. A dose of PCV20 appears to provide adequate protection. However, ongoing surveillance studies will be important to answer this question, and vac...
Which types of patients do you treat with prolonged antibiotics before obtaining a CT sinus?
If the patient has had symptoms of chronic rhinosinusitis for more than 7 days I would give a 10-day course of Levoquin. The symptoms I look for include purulent post-nasal drainage, nasal congestion, and lethargy. If the patient does not respond in 203 days, I would obtain a sinus CT.
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...