When to refer your patient to an allergistimmunologist

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When to refer your patient to an
allergist/immunologist
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How the Allergist/Immunologist Can
HelpConsultation 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

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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.
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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).
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• 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

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• 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-immunologis
  ts
• improve outcomes

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• How the Allergist/Immunologist Can
  HelpConsultation 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.

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• How the Allergist/Immunologist Can
  HelpConsultation 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.

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• How the Allergist/Immunologist Can
  HelpConsultation 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.

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• How the Allergist/Immunologist Can
  HelpConsultation 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 individuals 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.

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• How the Allergist/Immunologist Can
  HelpConsultation 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.

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• How the Allergist/Immunologist Can
  HelpConsultation 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.

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• 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/immunologis
  t 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

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• How the Allergist/Immunologist Can
  HelpConsultation 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.

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• How the Allergist/Immunologist Can
  HelpConsultation 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.

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• How the Allergist/Immunologist Can
  HelpConsultation 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.

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• How the Allergist/Immunologist Can
  HelpConsultation 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

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• How the Allergist/Immunologist Can
  HelpConsultation 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.

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• How the Allergist/Immunologist Can
  HelpConsultation 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

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• How the Allergist/Immunologist Can
  HelpConsultation 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.

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• How the Allergist/Immunologist Can
  HelpConsultation 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

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• How the Allergist/Immunologist Can
  HelpConsultation 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

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• How the Allergist/Immunologist Can
  HelpConsultation 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.

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• How the Allergist/Immunologist Can
  HelpConsultation 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.

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• How the Allergist/Immunologist Can
  HelpConsultation 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.

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• How the Allergist/Immunologist Can
  HelpConsultation 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

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• How the Allergist/Immunologist Can
  HelpConsultation 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