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Conway AE, Golden DBK, Brough HA, Santos AF, Shaker MS. Serologic measurements for peanut allergy: Predicting clinical severity is complex. Ann Allergy Asthma Immunol 2024; 132:686-693. [PMID: 38272114 DOI: 10.1016/j.anai.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/14/2024] [Accepted: 01/15/2024] [Indexed: 01/27/2024]
Abstract
Allergist-immunologists use serologic peanut allergy testing to maximize test sensitivity and specificity while minimizing cost and inconvenience. Recent advances toward this goal include a better understanding of specific IgE (sIgE) and component testing, epitope-sIgE assays, and basophil activation testing. Predicting reaction severity with serologic testing is challenged by a range of co-factors that influence reaction severity, such as the amount and form of any allergen consumed and comorbid disease. In 2020, the Allergy Immunology Joint Task Force on Practice Parameters recommended Ara h 2-sIgE as the most cost-effective diagnostic test for peanut allergy because of its superior performance, when compared with skin prick testing and serum IgE. Basophil activation testing, a functional test of allergic response not evaluated in the Joint Task Force on Practice Parameters guideline, is a promising option for both allergy diagnosis and prognosis. Similarly, epitope-sIgE testing may improve prediction of reaction thresholds, but further validation is needed. Despite advances in food allergy testing, many of these tools remain limited by cost, accessibility, and feasibility. In addition, there is a need for further research on how atopic dermatitis may be modifying serologic food allergy severity assessments. Given these limitations, allergy test selection requires a shared decision-making approach so that a patient's values and preferences regarding financial impact, inconvenience, and psychological effects are considered in the context of clinician expertise on the timing and use of optimized testing.
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Affiliation(s)
| | - David B K Golden
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Helen A Brough
- Department of Women and Children's Health (Pediatric Allergy), School of Life Courses Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom; Children's Allergy Service and Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas's NHS Foundation Trust, London, United Kingdom
| | - Alexandra F Santos
- Department of Women and Children's Health (Pediatric Allergy), School of Life Courses Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom; Children's Allergy Service and Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas's NHS Foundation Trust, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Marcus S Shaker
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire; Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
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Anagnostou A, Hearrell M, Timberlake D, Huang X, Staggers KA, Stukus D. Social media use among parents of children with food allergies. Ann Allergy Asthma Immunol 2024:S1081-1206(24)00208-4. [PMID: 38570161 DOI: 10.1016/j.anai.2024.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 04/05/2024]
Affiliation(s)
- Aikaterini Anagnostou
- Department of Pediatrics, Section of Immunology, Allergy, and Retrovirology, Texas Children's Hospital, Houston, Texas; Section of Allergy, Immunology, & Retrovirology, Baylor College of Medicine, Houston, Texas.
| | - Melissa Hearrell
- Department of Pediatrics, Section of Immunology, Allergy, and Retrovirology, Texas Children's Hospital, Houston, Texas; Section of Allergy, Immunology, & Retrovirology, Baylor College of Medicine, Houston, Texas
| | - Dylan Timberlake
- Prevea Health Allergy, Asthma, and Immunology, Altoona, Wisconsin
| | - Xiaofan Huang
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - Kristen A Staggers
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - David Stukus
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
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Laubach S, Kim EH, Greenhawt M, Bailey S, Anagnostou A. A Review of Shared Decision-Making, Published Protocols, and Post-desensitization Strategies in Oral Immunotherapy (OIT). Curr Allergy Asthma Rep 2024; 24:173-197. [PMID: 38441821 PMCID: PMC11008063 DOI: 10.1007/s11882-024-01132-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2024] [Indexed: 04/12/2024]
Abstract
PURPOSE OF REVIEW The aim of this review is to highlight key published oral immunotherapy (OIT) protocols and post-desensitization strategies for the major food allergens and to cover important concepts to consider when evaluating OIT for food-allergic patients. Shared decision-making should help identify patient and family values which will help influence the type of evidence-based protocol and maintenance strategy to use. RECENT FINDINGS With food OIT emerging as a treatment option, there is a pressing need for patients, physicians, and other providers to have a nuanced understanding of the management choices available to them. There are now randomized controlled trials (RCT) of OIT for peanut, egg, milk, and wheat, and reports of cohorts of patients who have undergone OIT for tree nuts and sesame clinically. The current published protocols contain significant diversity in terms of starting dose, build-up schedule, maintenance dose, and even the product used for desensitization. Emerging data can help direct the long-term maintenance strategy for patients on OIT. Based on patient and family values elicited through the shared decision-making process, an OIT protocol may be selected that balances the level of desensitization, potential side effects, frequency of clinic visits, and potential to induce sustained unresponsiveness, among other factors. Once maintenance dosing is reached, most patients will need to maintain regular exposure to the food allergen to remain desensitized. The option to transition to commercial food products with equivalent amounts of food protein as the OIT maintenance dose would simplify the dosing process and perhaps improve palatability as well. Less frequent or decreased OIT dosing can provide practical benefits but may affect the level of desensitization and safety for some patients.
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Affiliation(s)
- Susan Laubach
- Department of Pediatrics, University of California San Diego, San Diego, CA, USA.
- Division of Allergy, Immunology & Rheumatology, Rady Children's Hospital San Diego, San Diego, CA, USA.
| | - Edwin H Kim
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Food Challenge and Research Unit, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sally Bailey
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Georgetown University, Washington, DC, USA
- Allergy Associates of Northern Virginia, Arlington, VA, USA
| | - Aikaterini Anagnostou
- Department of Pediatrics, Section of Immunology, Allergy and Retrovirology, Texas Children's Hospital, Houston, TX, USA
- Section of Allergy, Immunology & Retrovirology, Baylor College of Medicine, Houston, TX, USA
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Stephen E, Conway AE, Codispoti CD, Abrams E, Lieberman JA, Ledford D, Pongdee T, Shaker M. Patient-Centered Practice Guidelines: GRADEing Evidence to Incorporate Certainty, Balance Between Benefits and Harms, Equity, Feasibility, and Cost-Effectiveness. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00269-1. [PMID: 38467331 DOI: 10.1016/j.jaip.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 02/20/2024] [Accepted: 03/01/2024] [Indexed: 03/13/2024]
Abstract
The practice of medicine in recent years has emphasized the use of evidence-based clinical guidelines to help inform treatment decisions. Since its development in 2004, the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach has offered a systematic process for reviewing and summarizing the certainty of evidence found in the medical literature regarding various treatment options. To develop truly patient-centered care guidelines, this appraisal of the certainty of evidence must be combined with an understanding of the balance between benefits and harms, patient preferences, equity, feasibility, cost-effectiveness, and policy implications. This review examines each of these domains in detail, exploring the process and benefits of developing relevant, patient-focused guidelines directly applicable to the practice of modern medicine.
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Affiliation(s)
- Ellen Stephen
- Department of Internal Medicine, Division of Allergy, Rush University Medical Center, Chicago, Ill
| | | | - Christopher D Codispoti
- Department of Internal Medicine, Division of Allergy, Rush University Medical Center, Chicago, Ill
| | - Elissa Abrams
- Department of Pediatrics, Section of Allergy and Immunology, University of Manitoba, Winnipeg, Man, Canada
| | - Jay A Lieberman
- Department of Pediatrics, The University of Tennessee Health Sciences Center, Memphis, Tenn
| | - Dennis Ledford
- Division of Allergy and Immunology, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, Fla
| | - Thanai Pongdee
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Marcus Shaker
- Department of Pediatrics and Internal Medicine, Dartmouth Geisel School of Medicine, Hanover, NH; Section of Allergy and Clinical Immunology, Dartmouth Hitchcock Medical Center, Lebanon, NH.
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Anagnostou A, Greenhawt M, Rodríguez Del Río P, Pickett G, Szafron V, Stukus D, Abrams EM. Addressing common questions on food oral immunotherapy: a practical guide for paediatricians. Arch Dis Child 2024:archdischild-2023-326225. [PMID: 38216305 DOI: 10.1136/archdischild-2023-326225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 12/13/2023] [Indexed: 01/14/2024]
Abstract
Food allergy has been increasing in prevalence in most westernised countries and poses a significant burden to patients and families; dietary and social limitations as well as psychosocial and economic burden affect daily activities, resulting in decreased quality of life. Food oral immunotherapy (food-OIT) has emerged as an active form of treatment, with multiple benefits such as increasing the threshold of reactivity to the allergenic food, decreasing reaction severity on accidental exposures, expanding dietary choices, reducing anxiety and generally improving quality of life. Risks associated with food immunotherapy mostly consist of allergic reactions during therapy. While the therapy is generally considered both safe and effective, patients and families must be informed of the aforementioned risks, understand them, and be willing to accept and hedge these risks as being worthwhile and outweighed by the anticipated benefits through a process of shared decision-making. Food-OIT is a good example of a preference-sensitive care paradigm, given candidates for this therapy must consider multiple trade-offs for what is considered an optional therapy for food allergy compared with avoidance. Additionally, clinicians who discuss OIT should remain increasingly aware of the growing impact of social media on medical decision-making and be prepared to counter misconceptions by providing clear evidence-based information during in-person encounters, on their website, and through printed information that families can take home and review.
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Affiliation(s)
- Aikaterini Anagnostou
- Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
| | - Matthew Greenhawt
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Grant Pickett
- Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
| | | | - David Stukus
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Elissa M Abrams
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
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Eghrari-Sabet J, Williams D, Bukstein DA, Winders T, Gardner DD. Real-world use and perceptions of shared decision-making for allergy and asthma care in a US population. World Allergy Organ J 2023; 16:100828. [PMID: 37859758 PMCID: PMC10582489 DOI: 10.1016/j.waojou.2023.100828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/14/2023] [Accepted: 09/21/2023] [Indexed: 10/21/2023] Open
Abstract
Background Shared decision-making (SDM), the process of engaging patients in their healthcare decisions, is an integral component of personalized medicine. The use of SDM in real-world allergy and asthma care in the United States (US) is unknown. Cross-sectional surveys of allergists and patients in a US population were conducted to assess the use and perceptions of SDM and SDM tools in real-world allergy and asthma care. Methods Allergists (N = 101) who were members of the American College of Allergy Asthma & Immunology (ACAAI) and who were also Dynata (a marketing research firm) research partners or in the Allergy & Asthma Network customer database completed an online survey from February-March 2022. Adult patients (N = 110) with asthma, allergy, and/or eczema in the United States who were participants of online research panels hosted by Dynata completed on online survey from February 1-7, 2022. Results Based on their own definition, 98% of the allergists reported familiarity with SDM, and 79% reported using it frequently. Allergists reported using SDM with an average of 44% of their patients. The most commonly used tool was the Immunotherapy SDM toolkit (40%); 43% had not used any SDM tool. Among allergists not using SDM or using it infrequently (n = 19), 42% considered it too time-consuming and 37% believed their patients have low health literacy. Of the surveyed patients, 25% reported their provider used SDM "frequently" or "occasionally" when being treated for allergies, asthma, or eczema, and 22% reported using SDM tools with their provider at some point. The most commonly used tool was the Asthma and Allergy Symptom Test (60%). Among patients whose allergists used SDM infrequently or never (n = 56), 70% reported they would be likely to ask their allergist to use SDM more often. Conclusion Survey responses revealed a disconnect between allergists and patients regarding SDM use. Barriers to SDM are consistent with those across the healthcare industry. Patients clearly expressed their desire for SDM.
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Affiliation(s)
| | - Dennis Williams
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina, Chapel Hill, NC, USA
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Shaker M, Abrams EM, Sublett JW. Contextual community epinephrine prescribing: Is more always better? Ann Allergy Asthma Immunol 2023; 131:176-184. [PMID: 37209832 DOI: 10.1016/j.anai.2023.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/11/2023] [Accepted: 05/05/2023] [Indexed: 05/22/2023]
Abstract
OBJECTIVE Prompt administration of epinephrine is first-line management of anaphylaxis. Although severe anaphylaxis may require more than 1 epinephrine dose, multiple epinephrine device packs may not be necessary for all patients at risk for allergic reactions. DATA SOURCES A narrative review was used to describe key considerations to contextualize community epinephrine prescribing. RESULTS Anaphylaxis has a lifetime prevalence of 1.6% to 5.1%. Meeting diagnostic criteria for anaphylaxis is not required for epinephrine treatment of a severe allergic reaction. A "1-2-3" approach to anaphylaxis treatment is important to clearly relay central management steps: promptly administer a first dose of intramuscular epinephrine with proper positioning, and activate emergency medical services if immediate symptom resolution does not occur; consider a second dose of intramuscular epinephrine with consideration of oxygen administration and intravenous fluid if initial epinephrine response is not adequate; and consider a third intramuscular epinephrine dose together with consideration of intravenous fluid support and oxygen for continued lack of appropriate response. Although multiple epinephrine doses may be required to treat severe anaphylaxis, 90% of anaphylaxis cases do not require more than 1 epinephrine dose. A universal requirement for multiple epinephrine devices in patients without a history of anaphylaxis is not cost-effective. Patients without a history of anaphylaxis may be managed without multiple device prescriptions within a patient-preference sensitive paradigm of care. CONCLUSION Anaphylaxis prevention involves appropriate education to avoid allergen triggers, recognize symptoms of an allergic reaction, rapidly access and administer intramuscular epinephrine, and appropriately activate emergency medical services when needed. For patients with previous anaphylaxis, particularly those who have required more than 1 dose of epinephrine to treat an allergic reaction, possessing multiple epinephrine devices is an important part of managing community anaphylaxis risk.
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Affiliation(s)
- Marcus Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Department of Medicine and Pediatrics, Dartmouth Geisel School of Medicine, Hanover, New Hampshire.
| | - Elissa M Abrams
- Section of Allergy and Clinical Immunology, Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
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Bjelac J, Shaker M, Greenhawt M, Kodish E. Viewing Pediatric Food Oral Immunotherapy Through an Ethical Lens-A Narrative Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1914-1925. [PMID: 36965706 DOI: 10.1016/j.jaip.2023.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 01/31/2023] [Accepted: 03/11/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Food allergy remains a common problem and a lifelong condition for many children. In recent years, food allergy management has increasingly involved conversations about food oral immunotherapy (OIT). Although ethical considerations of autonomy, beneficence, nonmaleficence, and justice implicitly inform these conversations, applying these principles can be complex, particularly in young children. Families of young children assume a role of surrogate decision-maker and must balance immediate risks with the hope of longer-term benefits. OBJECTIVE To explore implementation of OIT in children through an ethical lens. METHODS To evaluate OIT through an ethical lens, we conducted a literature search to explore currently published frameworks in this area. RESULTS Evaluation of the harm principle, the basic interest principle, and the best interest principle of parental decision-making can be informative. Shared decision-making continues to be central to the process of engaging with patient-family units to individualize the best care, at the right time, and minimize decisional discord. Although OIT is well-positioned to promote health and well-being, challenges to equity, sustainability, and organizational support must be considered to improve access for appropriate patients. CONCLUSIONS Whereas approaches to food OIT may be tailored to the individual context of each patient-family unit, ethical principles must guide decisions to initiate and continue therapy. Traditional ethical principles of autonomy, beneficence, nonmaleficence, and justice remain cornerstones when considering the ethical context of OIT.
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Affiliation(s)
- Jaclyn Bjelac
- Food Allergy Center of Excellence, Center for Pediatric Allergy and Immunology, Cleveland Clinic, Cleveland, Ohio.
| | - Marcus Shaker
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Food Challenge and Research Unit, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Eric Kodish
- Pediatric Hematology Oncology and Blood and Marrow Transplantation, Cleveland Clinic Children's and Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
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Shaker M. Allergies on vacation: It is a small world after all. Ann Allergy Asthma Immunol 2023; 130:399-400. [PMID: 37005044 DOI: 10.1016/j.anai.2022.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 04/03/2023]
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Jafri S, Janzen J, Kim R, Abrams EM, Gruber J, Protudjer JLP. Reply to "The intersection of sexual identity and race and ethnicity in allergic diseases". THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:974-975. [PMID: 36621606 DOI: 10.1016/j.jaip.2022.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 01/06/2023]
Affiliation(s)
- Syeda Jafri
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jacob Janzen
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rebecca Kim
- Faculty of Arts and Science, Department of Biomedical and Molecular Science, Queen's University, Kingston, Ontario, Canada
| | - Elissa M Abrams
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada; Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Jackie Gruber
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jennifer L P Protudjer
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada; Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada; Department of Food and Human Nutritional Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; George and Fay Yee Centre for Healthcare Innovation, Winnipeg, Manitoba, Canada; Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
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Shaker M, Mauger D, Fuhlbrigge AL. Value-Based, Cost-Effective Care: The Role of the Allergist-Immunologist. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:132-139. [PMID: 35944893 DOI: 10.1016/j.jaip.2022.07.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/19/2022] [Accepted: 07/21/2022] [Indexed: 01/11/2023]
Abstract
Asthma and allergic disease impact millions of patients and are associated with high costs. Up to 30% of all medical care involves wasted spending. Across the spectrum of care provided by the allergist-immunologist, there are opportunities to improve value and reduce medical waste. Several examples highlight this reality. Evidence suggests that most patients may receive cost-effective care in the management of chronic spontaneous urticaria without the need for laboratory testing. For patients with asthma, although a single maintenance and reliever therapy approach may be cost-effective, insurance-mandated therapy changes are not, and may harm patients. Biologics may be very effective in improving asthma control but are too expensive for this indication-as demonstrated by cost-effectiveness analyses and highlighted by the Institute of Clinical and Economic Review, which concluded that the value-based price for asthma biologics ranges between $6500 and 14,3000 per year. Early introduction may prevent food allergy, but screening before first introduction is neither necessary nor cost-effective, although early salvage food oral immunotherapy may result in improved quality of life and cost savings. Evidence does not support the presence of allergic disease as a risk factor for anaphylaxis to coronavirus disease 2019 vaccination, and risk-stratified vaccination approaches do not appear cost-effective. Allergen immunotherapy is a very cost-effective treatment option. The practice of allergy-immunology has continued to evolve in recent years and can provide a leading example of high-value practice.
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Affiliation(s)
- Marcus Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH.
| | - David Mauger
- Department of Public Health Sciences, Division of Biostatistics and Bioinformatics, The Pennsylvania State University, State College, Pa
| | - Anne L Fuhlbrigge
- Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo
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Abrams EM, Shaker M, Greenhawt M. La COVID-19 et l’importance d’une communication efficace des risques aux enfants. Paediatr Child Health 2022; 27:S79-S81. [PMID: 36092291 PMCID: PMC9455649 DOI: 10.1093/pch/pxac008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 12/23/2021] [Indexed: 11/14/2022] Open
Abstract
Il est essentiel de privilégier une communication efficace des risques pour atténuer les effets de la pandémie actuelle de COVID-19 sur la santé mentale des enfants et de leur famille. La communication efficace des risques consiste à faire preuve d’honnêteté tout en demeurant rassurant, à présenter les enjeux de manière pragmatique et à donner l’exemple d’une communication entre adultes rassurante, mais réaliste. Les professionnels de la santé peuvent échanger avec les familles sur les principes à suivre pour donner l’exemple de bonnes habitudes de consommation des médias et ainsi atténuer la mésinformation qui circule dans les réseaux sociaux. En outre, la numératie et la littératie en santé doivent être intégrées à une bonne communication des risques.
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Affiliation(s)
- Elissa M Abrams
- Département de pédiatrie et de santé de l’enfant, section des allergies et de l’immunologie, Université de Winnipeg (Manitoba) Canada
| | - Marcus Shaker
- Dartmouth-Hitchcok Medical Center, section des allergies et de l’immunologie, Lebanon (New Hampshire) États-Unis
- École de médecine Geisel à Dartmouth, Hanover (New Hampshire) États-Unis
| | - Matthew Greenhawt
- Children’s Hospital Colorado, École de médecine de l’Université du Colorado, section des allergies et de l’immunologie, Aurora (Colorado) États-Unis
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Abrams EM, Shaker M, Greenhawt M. COVID-19 and the importance of effective risk communication with children. Paediatr Child Health 2022; 27:S1-S3. [PMID: 35620559 PMCID: PMC9126270 DOI: 10.1093/pch/pxab101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 12/23/2021] [Indexed: 11/14/2022] Open
Abstract
During the current COVID-19 pandemic, effective risk communication is essential to mitigate the mental health impact on children and their families. Effective risk communication involves being honest but yet reassuring, framing issues in an actionable way, and modeling realistically reassuring communication among adults. Health care providers may discuss with families principles of modeling good media consumption habits to mitigate misinformation on social media. In addition, health numeracy and health literacy need to be integrated into proper risk communication.
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Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Immunology, The University of Manitoba, Winnipeg, Manitoba, Canada
- Correspondence: Elissa M. Abrams, Department of Pediatrics and Child Health, University of Manitoba, FE125-685 William Avenue, Winnipeg, Manitoba R2A 5L9, Canada. Telephone 204-255-7650, fax 204-254-0730, e-mail
| | - Marcus Shaker
- Dartmouth-Hitchcok Medical Center, Section of Allergy and Immunology, Lebanon, New Hampshire, USA
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Matthew Greenhawt
- Children’s Hospital Colorado, University of Colorado School of Medicine, Section of Allergy and Immunology, Aurora, Colorado, USA
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Abrams EM, Chan ES, Portnoy J. Evolving Interpretation of Screening and Diagnostic Tests in Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2021; 9:4183-4191. [PMID: 34893185 DOI: 10.1016/j.jaip.2021.05.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/17/2021] [Accepted: 05/23/2021] [Indexed: 06/14/2023]
Abstract
Diagnostic tests for allergy usually are performed to confirm a diagnosis of an allergic disease. If a food allergy suspected, a test can help to determine whether it is present, to monitor its activity over time, and to determine whether the allergy is resolving. In this way, tests are used for diagnosis, monitoring, screening, and prognosis. There are 2 schools of thought for using tests: Frequentist and Bayesian approaches. The Frequentist approach defines probability in terms of the frequency of an event if it were to be repeated numerous times and uses parameters such as sensitivity, specificity, and predictive values to make a diagnosis. In contrast, the Bayesian approach defines probability as the degree of belief or disbelief regarding the diagnosis and asserts that only data are real and that test parameters are to be inferred from the data. There are strengths and limitations to each approach; however, the Bayesian approach provides an algorithm leading to a disease probability. To use the Bayesian approach, test results need to be expressed as a likelihood ratio. This helps to determine how much the result of a test changes the probability of a particular diagnosis. Once a probability of disease is determined, decision thresholds need to be defined so that a treatment decision can be made. Using this Bayesian approach, the concept of a false-positive or false-negative test result becomes obsolete.
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Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada
| | - Edmond S Chan
- Division of Allergy & Immunology, Department of Pediatrics, the University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Jay Portnoy
- Section of Allergy/Immunology, Children's Mercy Hospital, Kansas City, Mo.
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15
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Abrams EM, Greenhawt M, Alqurashi W, Singer AG, Shaker M. The Revenge of Unintended Consequences of Anaphylaxis-Risk Overdiagnosis: How Far We Have Come and How Far We Have to Go. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3911-3917. [PMID: 34147680 DOI: 10.1016/j.jaip.2021.05.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/11/2021] [Accepted: 05/26/2021] [Indexed: 12/13/2022]
Abstract
Overdiagnosis of anaphylaxis risk is an underappreciated aspect of anaphylaxis prevention. Whereas the benefits of anaphylaxis-risk prevention are well known, potential harms resulting from preemptive approaches to mitigate anaphylaxis-risk are not insignificant. Still, great progress has been made in recent years to avoid the unintended consequences of anaphylaxis-risk overdiagnosis. Reflection on recent advances in the use of diagnostic testing, as well as the application of diagnostic labels, provides an important perspective to understand how far the specialty of allergy and immunology has come in improving the lives of patients and families. Examples of recent paradigm shifts in anaphylaxis-risk management include approaches to peanut allergy prevention without screening, deferral of corticosteroids to prevent biphasic anaphylaxis reactions, reevaluation of reflex use of emergency medical services for resolved community anaphylaxis, and an approach to penicillin allergy delabeling with direct oral challenge. Routine medical practices to decrease anaphylaxis risk can have lifelong impacts for patients-beyond just preventing anaphylaxis. As our understanding of these trade-offs evolves, it becomes necessary to weigh both the benefits and the harms of past management approaches. Because medicine remains a science of uncertainty and an art of probability, a critical approach to risk mitigation remains necessary to find the often-elusive balance in anaphylaxis prevention.
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Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Canada
| | - Matthew Greenhawt
- Department of Pediatrics, Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Waleed Alqurashi
- Department of Pediatrics and Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
| | | | - Marcus Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Medicine and Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH.
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16
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Anagnostou A. Optimizing Patient Care in Egg Allergy Diagnosis and Treatment. J Asthma Allergy 2021; 14:621-628. [PMID: 34135601 PMCID: PMC8197590 DOI: 10.2147/jaa.s283307] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 05/21/2021] [Indexed: 01/01/2023] Open
Abstract
Egg allergy occurs frequently in childhood with a reported prevalence of 1.3–1.6%. Providing optimal care to egg-allergic patients requires knowledge of the most up-to-date developments in both diagnosis and management, as well as effective communication skills, which will engage the patient in the shared decision-making process. This review aims to provide up-to-date information on egg allergy and also serve as a concise guide on optimal patient diagnosis and management. The field of food allergy has seen multiple advances in recent years, including use of component resolved diagnostics, early egg introduction into the infant diet as a way of preventing egg allergy, baked egg introduction and oral immunotherapy as a form of active therapy. Faced with a variety of options and treatment paths, it is important to ensure that patients and families taking part in the decision-making process have fully understood the potential outcomes and trade-offs and can undertake a detailed discussion of all options that are available to them. Shared decision-making remains the cornerstone of optimal patient care.
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Affiliation(s)
- Aikaterini Anagnostou
- Baylor College of Medicine, Section of Pediatric Immunology, Allergy and Retrovirology, Houston, TX, USA.,Texas Children's Hospital, Department of Pediatrics, Section of Immunology, Allergy and Retrovirology, Houston, TX, USA
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17
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Shaker M, Phillips E, Blumenthal KG, Abrams EM, Banerji A, Oppenheimer J, Vander Leek TK, Mack DP, Wickner PG, Singer AG, Khan DA, Greenhawt M. The Importance of a Timely Second Dose of the 2021 COVID-19 mRNA Vaccine Depends on the Protection Afforded by a First Dose and Subsequent Risk of Anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2556-2561. [PMID: 33892171 PMCID: PMC8056986 DOI: 10.1016/j.jaip.2021.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/23/2021] [Accepted: 04/15/2021] [Indexed: 12/16/2022]
Abstract
Vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) represents our greatest hope to combat the devastating coronavirus disease 2019 (COVID-19) pandemic. Amid ongoing global vaccination efforts, rare cases of severe allergic reactions to COVID-19 mRNA vaccines have received significant attention. Although the exact nature of these reactions may be heterogeneous, various approaches exist to engage with patients, communities, public health departments, primary care providers, and other clinicians in a multidisciplinary approach to advance population health. Whereas it is optimal for patients to receive COVID-19 vaccination as outlined in emergency use authorizations, second-dose deferral of mRNA vaccines may be a consideration within a shared decision-making paradigm of care in select circumstances characterized by high durable first-vaccine–dose protection and significant elevations of vaccine anaphylaxis risk. Still, the durability of protection afforded by a single dose of a COVID-19 mRNA vaccine is uncertain, and alternative approaches to complete vaccination, including precautionary use of a COVID-19 viral vector vaccine, also remain patient-preference–sensitive options. There is an urgent need to define correlates of COVID-19 immunity and the level of longer-term protection afforded by COVID-19 vaccination.
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Affiliation(s)
- Marcus Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH.
| | - Elizabeth Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Mass
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | | | - Timothy K Vander Leek
- Pediatric Allergy and Asthma, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Douglas P Mack
- McMaster University, Hamilton, and Halton Pediatric Allergy, Burlington, Ontario, Canada
| | - Paige G Wickner
- Harvard Medical School, Boston, Mass; Division of Allergy and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Alexander G Singer
- Department of Family Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David A Khan
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matthew Greenhawt
- Department of Pediatrics, Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado Denver School of Medicine, Denver, Colo
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18
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School Attendance, Asthma Risk, and COVID-19 in Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2145-2150. [PMID: 33744475 PMCID: PMC8770849 DOI: 10.1016/j.jaip.2021.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/01/2021] [Accepted: 03/01/2021] [Indexed: 12/11/2022]
Abstract
In the face of tremendous uncertainty during the current pandemic, there is a need for clear and consistent recommendations and an understanding of the evidence in general, and for families of children with allergic conditions. A common concern of parents of children with asthma is the risk that in-person learning poses during the pandemic. This Rostrum examines the actual risk of in-person learning among children with asthma during novel coronavirus disease 2019 (COVID-19), the discrepancy between perceived and actual risk, the contributing factors to this discrepancy, and possible solutions to narrow this divide. Overall, the evidence does not support that children with asthma are at an increased risk of COVID-19 morbidity or mortality compared with children without asthma. Asthma medications do not appear to contribute to incidence or severity of COVID-19 disease. However, there is a high perceived risk of in-person learning that is partially related to how it is portrayed in the media. There is little guidance regarding transitioning asthmatic children back to school and how to properly counsel on mediation of risk. There are differences regionally and locally around school reopening, exemptions, and their implementation. To narrow the divide between perceived and actual risk, clear consistent and ongoing communication will be necessary.
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19
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Wasserman RL, Factor J, Windom HH, Abrams EM, Begin P, Chan ES, Greenhawt M, Hare N, Mack DP, Mansfield L, Ben-Shoshan M, Stukus DR, Leek TV, Shaker M. An Approach to the Office-Based Practice of Food Oral Immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1826-1838.e8. [PMID: 33684637 DOI: 10.1016/j.jaip.2021.02.046] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/30/2021] [Accepted: 02/25/2021] [Indexed: 12/13/2022]
Abstract
Oral immunotherapy (OIT) provides an active treatment option for patients with food allergies. OIT may improve quality of life and raise the threshold at which a patient with food allergy may react to an allergen, but it is a rigorous therapy that requires a high degree of commitment by the clinician, patients, and families. Recent guidelines from the Canadian Society for Allergy and Clinical Immunology have provided a framework for the ethical, evidence-based, and patient-oriented clinical practice of OIT, and the European Academy of Allergy, Asthma, and Immunology guidelines have also recommended that OIT can be used as a potential treatment. The recent Food and Drug Administration approval of an OIT pharmaceutical has accelerated the adoption of OIT. This review provides a summary of the recent Canadian Society for Allergy and Clinical Immunology guidelines and a consensus of practical experience of clinicians across the United States and Canada related to patient selection, office and staff preparation, the general OIT process, OIT-related reaction management, and treatment outcomes.
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Affiliation(s)
| | - Jeffrey Factor
- New England Food Allergy Treatment Center, West Hartford, Conn
| | - Hugh H Windom
- Windom Allergy, Asthma and Sinus Specialists, Sarasota, Fla
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada
| | - Philippe Begin
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Université de Montréal, Montreal, QC, Canada
| | - Edmond S Chan
- Division of Allergy & Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Food Challenge and Research Unit, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | | | - Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | | | - Moshe Ben-Shoshan
- Division of Allergy Immunology and Dermatology, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | | | - Marcus Shaker
- Geisel School of Medicine at Dartmouth, Hanover, NH; Dartmouth-Hitchcock Medical Center, Lebanon, NH.
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20
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An update on international practice variation in peanut introduction: conundrums, controversies, and a new direction. Curr Opin Pediatr 2020; 32:825-831. [PMID: 33060444 DOI: 10.1097/mop.0000000000000957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Introduction of peanut during the first year of life is associated with an 81% relative risk reduction of developing peanut allergy in infants with severe eczema, egg allergy, or both. However, significant international variation exists in risk stratification prior to peanut introduction. RECENT FINDINGS A policy-level screening approach, such as the one in the United States, is not practical and is associated with higher costs and more cases of peanut allergy over time, in contrast to international models that recommend universal early introduction without prescreening. In Australia, population-level efforts to introduce peanut early without screening have demonstrated high rates of peanut introduction before 12 months of age and low rates of severe allergic reactions. In contrast, screening prior to peanut introduction in the United States is associated with 'screening creep' - the tendency of clinicians to test populations where screening is not recommended. SUMMARY Early peanut introduction can reduce the risk of developing food allergy and is more effective without a risk-based screening approach. In some circumstances, shared clinical decision-making can facilitate food allergy prevention in a manner consistent with family values and preferences.
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21
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Le Blanc V, Samaan K, Paradis L, Lacombe-Barrios J, Graham FJ, Des Roches A, Bégin P. Treatment expectations in food-allergic patients referred for oral immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:2087-2089. [PMID: 33248283 DOI: 10.1016/j.jaip.2020.11.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Vicky Le Blanc
- Section of Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Kathryn Samaan
- Section of Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Louis Paradis
- Section of Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada; Section of Allergy and Immunology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Jonathan Lacombe-Barrios
- Section of Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - François J Graham
- Section of Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada; Section of Allergy and Immunology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Anne Des Roches
- Section of Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Philippe Bégin
- Section of Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada; Section of Allergy and Immunology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.
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22
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Wu AC, Fuhlbrigge AL, Robayo MA, Shaker M. Cost-Effectiveness of Biologics for Allergic Diseases. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1107-1117.e2. [PMID: 33069886 DOI: 10.1016/j.jaip.2020.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/17/2020] [Accepted: 10/05/2020] [Indexed: 12/20/2022]
Abstract
The introduction of specific humanized monoclonal antibodies over the past 20 years has dramatically changed the treatment of allergic diseases. At present, 5 mAbs are licensed for treating moderate to severe allergic and eosinophilic asthma, atopic dermatitis, chronic spontaneous urticaria, chronic sinusitis with nasal polyps, and eosinophilic granulomatosis with polyangiitis. Given the high costs of biologics, understanding their cost-effectiveness is critical. As new biologics are developed and new indications are approved for existing biologics, the use of biologics for allergic diseases will increase. Conducting cost-effectiveness evaluations in parallel to efficacy and effectiveness trials will help patients, providers, payers, and policymakers in decision making.
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Affiliation(s)
- Ann Chen Wu
- Center for Healthcare Research in Pediatrics, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass.
| | - Anne L Fuhlbrigge
- Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo
| | - Maria Acosta Robayo
- Center for Healthcare Research in Pediatrics, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | - Marcus Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH; Geisel School of Medicine at Dartmouth, Departments of Pediatrics, of Medicine, and of Community and Family Medicine, Hanover, NH
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23
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Greenhawt M, Shaker M, Stukus DR, Fleischer DM, Hourihane J, Tang MLK, Abrams EM, Wang J, Bingemann TA, Chan ES, Lieberman J, Sampson HA, Bock SA, Young MC, Waserman S, Mack DP. Managing Food Allergy in Schools During the COVID-19 Pandemic. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2020; 8:2845-2850. [PMID: 32711118 PMCID: PMC7375974 DOI: 10.1016/j.jaip.2020.07.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 01/08/2023]
Abstract
In the wake of the COVID-19 pandemic and massive disruptions to daily life in the spring of 2020, in May 2020, the Centers for Disease Control (CDC) released guidance recommendations for schools regarding how to have students attend while adhering to principles of how to reduce the risk of contracting SARS-CoV-2. As part of physical distancing measures, the CDC is recommending that schools who traditionally have had students eat in a cafeteria or common large space instead have children eat their lunch or other meals in the classroom at already physically distanced desks. This has sparked concern for the safety of food-allergic children attending school, and some question of how the new CDC recommendations can coexist with recommendations in the 2013 CDC Voluntary Guidelines on Managing Food Allergy in Schools as well as accommodations that students may be afforded through disability law that may have previously prohibited eating in the classroom. This expert consensus explores the issues related to evidence-based management of food allergy at school, the issues of managing the health of children attending school that are acutely posed by the constraints of an infectious pandemic, and how to harmonize these needs so that all children can attend school with minimal risk from both an infectious and allergic standpoint.
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Affiliation(s)
- Matthew Greenhawt
- Department of Pediatrics, Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.
| | - Marcus Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH; Department of Pediatrics, Dartmouth Children's Hospital, Dartmouth Geisel School of Medicine, Hanover, NH
| | - David R Stukus
- Department of Pediatrics, Division of Allergy and Immunology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - David M Fleischer
- Department of Pediatrics, Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | | | - Mimi L K Tang
- Department of Allergy and Immunology, The Royal Children's Hospital Melbourne, Murdoch Children's Research Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Elissa M Abrams
- Section of Allergy and Clinical Immunology, Department of Pediatrics and Child Health, The University of Manitoba, Winnipeg, Manitoba, Canada
| | - Julie Wang
- Department of Pediatrics, Division of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Theresa A Bingemann
- University of Rochester Division of Allergy, Immunology and Rheumatology, Rochester, NY
| | - Edmond S Chan
- BC Children's Hospital, Division of Allergy & Immunology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Jay Lieberman
- Division of Allergy and Immunology, The University of Tennessee, Memphis, TN
| | - Hugh A Sampson
- Department of Pediatrics, Division of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY; DBV Technologies, Montrouge, France
| | - S Allan Bock
- Deptartment of Pediatrics, University of Colorado School of Medicine (Emeritus), Aurora, Colo
| | - Michael C Young
- Division of Allergy & Immunology, Children's Hospital Boston, Harvard Medical School, Boston, Mass
| | - Susan Waserman
- Department of Medicine, Clinical Immunology and Allergy, McMaster University, Hamilton, Ontario, Canada
| | - Douglas P Mack
- Department of Medicine, Clinical Immunology and Allergy, McMaster University, Hamilton, Ontario, Canada; Halton Pediatric Allergy, Burlington, Ontario, Canada
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Mack DP, Chan ES, Shaker M, Abrams EM, Wang J, Fleischer DM, Hanna MA, Greenhawt M. Novel Approaches to Food Allergy Management During COVID-19 Inspire Long-Term Change. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2020; 8:2851-2857. [PMID: 32721605 PMCID: PMC7382335 DOI: 10.1016/j.jaip.2020.07.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/18/2020] [Accepted: 07/20/2020] [Indexed: 01/08/2023]
Abstract
The SARS-CoV2 pandemic has prompted a re-evaluation of our current practice of medicine. The seemingly abrupt worldwide spread of this disease resulted in immediate changes and a reduction in many allergy-focussed services and procedures. The reality of the long-term circulation of this virus in our communities requires us to evolve as a specialty. In this article, we outline current and future challenges in the management of food allergy in light of coronavirus disease 2019 (COVID-19). We focus on infant food allergy prevention, management of anaphylaxis, accurate diagnosis with oral food challenges, and active management of food allergy with oral immunotherapy. This article identifies the challenges of conflicting guidelines, shortcomings of acute management approaches, and inherent system deficiencies. We offer perspectives and strategies that can be implemented now, including an evaluation of virtual care and telemedicine for the management of food allergy. The use of a shared decision-making model results in novel approaches that can benefit our patients and our specialty for years to come. COVID-19 has forced us to re-evaluate our current way of thinking about food allergy management to better treat our patients.
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Affiliation(s)
- Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada.
| | - Edmond S Chan
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marcus Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Elissa M Abrams
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Julie Wang
- Division of Allergy and Immunology, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David M Fleischer
- Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Mariam A Hanna
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
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25
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Keeping risk in context while rethinking the setting of asthma biologics in patient-centered care. Ann Allergy Asthma Immunol 2020; 125:124-125. [PMID: 32497713 PMCID: PMC7263209 DOI: 10.1016/j.anai.2020.05.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/24/2020] [Accepted: 05/25/2020] [Indexed: 01/05/2023]
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26
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Shaker MS, Oppenheimer J, Wallace DV, Golden DBK, Lang DM, Lang ES, Bernstein JA, Campbell RL, Chu D, Dinakar C, Ellis AK, Greenhawt M, Horner C, Lieberman JA, Rank MA, Stukus DR, Wang J. Making the GRADE in anaphylaxis management: Toward recommendations integrating values, preferences, context, and shared decision making. Ann Allergy Asthma Immunol 2020; 124:526-535.e2. [PMID: 32199979 DOI: 10.1016/j.anai.2020.03.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 03/09/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To review GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methods and discuss the clinical application of conditional recommendations in clinical guidelines, specifically in the context of anaphylaxis. DATA SOURCES Articles that described GRADE, evidence synthesis, evidence to recommendation frameworks, and shared decision making were used to discuss conditional recommendations of the 2020 Anaphylaxis GRADE guideline. STUDY SELECTIONS A narrative review detailing concepts of GRADE and approaches to translate conditional recommendations to individualized and contextualized patient care. RESULTS GRADE methods encourage a nuanced relationship between certainty of evidence and strength of recommendations. Strength of recommendation must incorporate key factors, including the balance between benefits and harms, patient values and preferences, and resource allocation (costs), with equity, feasibility, and acceptability also often included as considerations. GRADE guidelines provide recommendations that are characterized by directionality (for or against) and strength (strong or conditional). A conditional recommendation is tailored to context and primarily applied through a lens of patient preferences related to the likelihood of outcomes of importance and a shared decision-making approach. Although the 2020 Anaphylaxis GRADE guideline better informs the practice of anaphylaxis prevention through (1) identification and mitigation of risk factors for biphasic anaphylaxis and (2) evaluation of the use of glucocorticoid and/or antihistamine pretreatment, all GRADE recommendations, although directional, are conditional and as such should not be universally applied to every circumstance. CONCLUSION Clinical guidelines provide an important opportunity to critically appraise evidence and translate evidence to practice. Patients, practitioners, and policy makers should appreciate the strength of recommendation and certainty of evidence and understand how this affects guideline applicability and implementation.
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Affiliation(s)
- Marcus S Shaker
- Section of Allergy and Clinical Immunology, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.
| | - John Oppenheimer
- Department of Internal Medicine, Pulmonary and Allergy, UMDNJ-Rutgers New Jersey Medical School and Pulmonary and Allergy Associates, Morristown, New Jersey
| | - Dana V Wallace
- Nova Southeastern Allopathic Medical School, Fort Lauderdale, Florida
| | - David B K Golden
- Division of Allergy-Clinical Immunology, Johns Hopkins University, Baltimore, Maryland
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eddy S Lang
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Derek Chu
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Chitra Dinakar
- Allergy, Asthma, and Immunodeficiency, Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University School of Medicine, Stanford, California
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Denver, Colorado
| | - Caroline Horner
- Department of Pediatrics, Division of Allergy, Immunology, and Pulmonary Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Jay A Lieberman
- Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Scottsdale, Arizona
| | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Julie Wang
- Division of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, New York
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