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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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Conway AE, Lieberman J, Codispoti CD, Mahdavinia M, Anagnostou A, Hsu Blatman KS, Lang DM, Oppenheimer J, Mosnaim GS, Bukstein D, Shaker M. Pharmacoequity and Biologics in the Allergy Clinic: Providing the Right Care, at the Right Time, Every Time, to Everyone. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1170-1180. [PMID: 38458435 DOI: 10.1016/j.jaip.2024.02.039] [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: 01/09/2024] [Revised: 02/10/2024] [Accepted: 02/28/2024] [Indexed: 03/10/2024]
Abstract
Pharmacoequity refers to equity in access to pharmacotherapy for all patients and is an especially large barrier to biologic agents in patients with allergic diseases. Value-based care models can prompt clinicians to address social determinants of health, promoting pharmacoequity. Pharmacoequity is influenced by numerous factors including socioeconomic status, which may be mediated through insurance status, educational attainment, and access to specialist care. In addition to lower socioeconomic status, race and ethnicity, age, locations isolated from care systems, and off-label indications for biologic agents all constitute barriers to pharmacoequity. Whereas pharmaco-inequity is more apparent for expensive biologics, it also affects many other allergy treatments including epinephrine autoinjectors and SMART for asthma. Current programs aimed at alleviating cost barriers are imperfect. Patient assistance programs, manufacturer-sponsored free drug programs, and rebates often increase the complexity of care, with resultant inequity, particularly for patients with lower health literacy. Ultimately, single silver-bullet solutions are elusive. Long-term improvement instead requires a combination of research, advocacy, and creative problem-solving to design more intelligent and efficient systems that provide timely access to necessary care for every patient, every time.
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Affiliation(s)
| | - Jay Lieberman
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tenn
| | - Christopher D Codispoti
- Department of Internal Medicine, Division of Allergy, Rush University Medical Center, Chicago, Ill
| | - Mahboobeh Mahdavinia
- Department of Internal Medicine, Division of Allergy, Rush University Medical Center, Chicago, Ill
| | | | - Karen S Hsu Blatman
- Section of Allergy and Clinical Immunology, Dartmouth Hitchcock Medical Center, Lebanon, NH; Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - David M Lang
- Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio
| | | | - Giselle S Mosnaim
- Division of Allergy and Immunology, Department of Medicine, NorthShore University Health System, Evanston, Ill
| | - Don Bukstein
- Allergy, Asthma, and Sinus Center, Milwaukee, Wis
| | - Marcus Shaker
- Section of Allergy and Clinical Immunology, Dartmouth Hitchcock Medical Center, Lebanon, NH; Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH.
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3
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Chu X, Wang J, Ologundudu L, Brignardello-Petersen R, Guyatt GH, Oykhman P, Bernstein JA, Saini SS, Beck LA, Waserman S, Moellman J, Khan DA, Ben-Shoshan M, Baker DR, Oliver ET, Sheikh J, Lang D, Mathur SK, Winders T, Eftekhari S, Gardner DD, Runyon L, Asiniwasis RN, Cole EF, Chan J, Wheeler KE, Trayes KP, Tran P, Chu DK. Efficacy and Safety of Systemic Corticosteroids for Urticaria: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00400-8. [PMID: 38642709 DOI: 10.1016/j.jaip.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Short courses of adjunctive systemic corticosteroids are commonly used to treat acute urticaria and chronic urticaria flares (both with and without mast cell-mediated angioedema), but their benefits and harms are unclear. OBJECTIVE To evaluate the efficacy and safety of treating acute urticaria or chronic urticaria flares with versus without systemic corticosteroids. METHODS We searched the MEDLINE, EMBASE, CENTRAL, CNKI, VIP, Wanfang, and CBM databases from inception to July 8, 2023, for randomized controlled trials of treating urticaria with versus without systemic corticosteroids. Paired reviewers independently screened records, extracted data, and appraised risk of bias with the Cochrane 2.0 tool. We performed random-effects meta-analyses of urticaria activity, itch severity, and adverse events. We assessed certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluations (GRADE) approach. RESULTS We identified 12 randomized trials enrolling 944 patients. For patients with low or moderate probability (17.5%-64%) to improve with antihistamines alone, add-on systemic corticosteroids likely improve urticaria activity by a 14% to 15% absolute difference (odds ratio [OR], 2.17, 95% confidence interval [CI]: 1.43-3.31; number needed to treat [NNT], 7; moderate certainty). Among patients with a high chance (95.8%) for urticaria to improve with antihistamines alone, add-on systemic corticosteroids likely improved urticaria activity by a 2.2% absolute difference (NNT, 45; moderate certainty). Corticosteroids may improve itch severity (OR, 2.44; 95% CI: 0.87-6.83; risk difference, 9%; NNT, 11; low certainty). Systemic corticosteroids also likely increase adverse events (OR, 2.76; 95% CI: 1.00-7.62; risk difference, 15%; number needed to harm, 9; moderate certainty). CONCLUSIONS Systemic corticosteroids for acute urticaria or chronic urticaria exacerbations likely improve urticaria, depending on antihistamine responsiveness, but also likely increase adverse effects in approximately 15% more.
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Affiliation(s)
- Xiajing Chu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Evidence in Allergy Group, McMaster University, Hamilton, ON, Canada
| | - Jason Wang
- Evidence in Allergy Group, McMaster University, Hamilton, ON, Canada
| | | | - Romina Brignardello-Petersen
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Evidence in Allergy Group, McMaster University, Hamilton, ON, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Evidence in Allergy Group, McMaster University, Hamilton, ON, Canada
| | - Paul Oykhman
- Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jonathan A Bernstein
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Sarbjit S Saini
- Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Lisa A Beck
- Department of Dermatology, University of Rochester Medical Center, Rochester, NY
| | - Susan Waserman
- Evidence in Allergy Group, McMaster University, Hamilton, ON, Canada; Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Joseph Moellman
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Dave A Khan
- Department of Internal Medicine, Division of Allergy and Immunology, the University of Texas Southwestern Medical Center, Dallas, Texas
| | - Moshe Ben-Shoshan
- Department of Pediatrics, Division of Allergy, Immunology and Dermatology, McGill University, Montreal, QC, Canada
| | - Diane R Baker
- Department of Dermatology, Oregon Health & Sciences University, Portland, Ore
| | - Eric T Oliver
- Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Javed Sheikh
- Department of Clinical Immunology and Allergy, Southern California Permanente Medical Group, Los Angeles, Calif
| | - David Lang
- Allergy/Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Sameer K Mathur
- Division of Allergy, Pulmonary and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Tonya Winders
- Global Allergy & Airways Patient Platform, Vienna, Austria
| | | | | | - Lauren Runyon
- Department of Internal Medicine, Division of Allergy and Immunology, the University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Emily F Cole
- Department of Dermatology, Duke University, Durham, NC
| | - Jeffrey Chan
- Emergency Medicine, Southlake Regional Health Centre, Newmarket, ON, Canada
| | | | - Kathryn P Trayes
- Department of Family and Community Medicine, Thomas Jefferson University Hospital, Philadelphia, Pa
| | - Paul Tran
- University of Arizona College of Medicine, Phoenix Children's Hospital, Phoenix, Ariz
| | - Derek K Chu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Evidence in Allergy Group, McMaster University, Hamilton, ON, Canada; Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON, Canada; The Research Institute of St. Joe's Hamilton, Hamilton, ON, Canada.
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Shaker M. Optimizing clinical practice today while pondering an extraordinary immune system. Ann Allergy Asthma Immunol 2024; 132:411-412. [PMID: 38569751 DOI: 10.1016/j.anai.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 04/05/2024]
Affiliation(s)
- Marcus Shaker
- Departments of Medicine and Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
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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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6
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Chu DK, Schneider L, Asiniwasis RN, Boguniewicz M, De Benedetto A, Ellison K, Frazier WT, Greenhawt M, Huynh J, Kim E, LeBovidge J, Lind ML, Lio P, Martin SA, O'Brien M, Ong PY, Silverberg JI, Spergel JM, Wang J, Wheeler KE, Guyatt GH, Capozza K, Begolka WS, Chu AWL, Zhao IX, Chen L, Oykhman P, Bakaa L, Golden D, Shaker M, Bernstein JA, Greenhawt M, Horner CC, Lieberman J, Stukus D, Rank MA, Wang J, Ellis A, Abrams E, Ledford D, Chu DK. Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine-based recommendations. Ann Allergy Asthma Immunol 2024; 132:274-312. [PMID: 38108679 DOI: 10.1016/j.anai.2023.11.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Guidance addressing atopic dermatitis (AD) management, last issued in 2012 by the American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force, requires updating as a result of new treatments and improved guideline and evidence synthesis methodology. OBJECTIVE To produce evidence-based guidelines that support patients, clinicians, and other decision-makers in the optimal treatment of AD. METHODS A multidisciplinary guideline panel consisting of patients and caregivers, AD experts (dermatology and allergy/immunology), primary care practitioners (family medicine, pediatrics, internal medicine), and allied health professionals (psychology, pharmacy, nursing) convened, prioritized equity, diversity, and inclusiveness, and implemented management strategies to minimize influence of conflicts of interest. The Evidence in Allergy Group supported guideline development by performing systematic evidence reviews, facilitating guideline processes, and holding focus groups with patient and family partners. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach informed rating the certainty of evidence and strength of recommendations. Evidence-to-decision frameworks, subjected to public comment, translated evidence to recommendations using trustworthy guideline principles. RESULTS The panel agreed on 25 recommendations to gain and maintain control of AD for patients with mild, moderate, and severe AD. The eAppendix provides practical information and implementation considerations in 1-2 page patient-friendly handouts. CONCLUSION These evidence-based recommendations address optimal use of (1) topical treatments (barrier moisturization devices, corticosteroids, calcineurin inhibitors, PDE4 inhibitors [crisaborole], topical JAK inhibitors, occlusive [wet wrap] therapy, adjunctive antimicrobials, application frequency, maintenance therapy), (2) dilute bleach baths, (3) dietary avoidance/elimination, (4) allergen immunotherapy, and (5) systemic treatments (biologics/monoclonal antibodies, small molecule immunosuppressants [cyclosporine, methotrexate, azathioprine, mycophenolate, JAK inhibitors], and systemic corticosteroids) and UV phototherapy (light therapy).
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Affiliation(s)
- Derek K Chu
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University and The Research Institute of St. Joe's Hamilton, Hamilton, Canada.
| | - Lynda Schneider
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts.
| | | | - Mark Boguniewicz
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Division of Pediatric Allergy and Clinical Immunology, National Jewish Health, Denver, Colorado
| | - Anna De Benedetto
- Department of Dermatology, University of Rochester Medical Center, Rochester, New York
| | | | - Winfred T Frazier
- Department of Family Medicine, UPMC St. Margaret, Pittsburgh, Pennsylvania
| | - Matthew Greenhawt
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Section of Allergy and Immunology, Children's Hospital Colorado, Aurora, Colorado
| | - Joey Huynh
- Sepulveda VA Medical Center, North Hills, California
| | | | - Jennifer LeBovidge
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Mary Laura Lind
- School for Engineering of Matter, Transport and Energy, Arizona State University, Tempe, Arizona
| | - Peter Lio
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stephen A Martin
- University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Monica O'Brien
- Tufts University School of Medicine, Boston, Massachusetts
| | - Peck Y Ong
- Division of Clinical Immunology and Allergy, Children's Hospital Los Angeles, Los Angeles, California; Department of Pediatrics, USC Keck School of Medicine, Los Angeles, California
| | - Jonathan I Silverberg
- Department of Dermatology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Jonathan M Spergel
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Julie Wang
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Kathryn E Wheeler
- Department of Pediatrics, University of Florida, Gainesville, Florida
| | - Gordon H Guyatt
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University and The Research Institute of St. Joe's Hamilton, Hamilton, Canada
| | - Korey Capozza
- Global Parents for Eczema Research, Santa Barbara, California
| | | | - Alexandro W L Chu
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University and The Research Institute of St. Joe's Hamilton, Hamilton, Canada
| | - Irene X Zhao
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University and The Research Institute of St. Joe's Hamilton, Hamilton, Canada
| | - Lina Chen
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University and The Research Institute of St. Joe's Hamilton, Hamilton, Canada
| | - Paul Oykhman
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University and The Research Institute of St. Joe's Hamilton, Hamilton, Canada
| | - Layla Bakaa
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University and The Research Institute of St. Joe's Hamilton, Hamilton, Canada
| | - David Golden
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marcus Shaker
- Dartmouth Geisel School of Medicine and Dartmouth Hitchcock Medical Center, Section of Allergy, Lebanon, New Hampshire
| | | | - Matthew Greenhawt
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Section of Allergy and Immunology, Children's Hospital Colorado, Aurora, Colorado
| | - Caroline C Horner
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Jay Lieberman
- University of Tennessee Health Science Center and LeBonheur Children's Hospital, Memphis, Tennessee
| | - David Stukus
- Nationwide Children's Hospital and Ohio State University College of Medicine, Columbus, Ohio
| | - Matthew A Rank
- Mayo Clinic in Arizona and Phoenix Children's Hospital, Scottsdale and Phoenix, Arizona
| | - Julie Wang
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Anne Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Elissa Abrams
- Section of Allergy and Clinical Immunology, Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Dennis Ledford
- Morsani College of Medicine, University of South Florida and James A. Haley Veterans' Affairs Hospital, Tampa, Florida
| | - Derek K Chu
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University and The Research Institute of St. Joe's Hamilton, Hamilton, Canada
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Shaker M, Sublett JW, Abrams EM. Treating the patient in front of you. Ann Allergy Asthma Immunol 2024; 132:102-103. [PMID: 38123278 DOI: 10.1016/j.anai.2023.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 12/23/2023]
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
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8
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Shaker M, Golden DBK. More than 80 years of excellence and collaboration in allergy … and just getting started. Ann Allergy Asthma Immunol 2024; 132:3-4. [PMID: 38123280 DOI: 10.1016/j.anai.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 02/08/2023] [Accepted: 02/08/2023] [Indexed: 12/23/2023]
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.
| | - David B K Golden
- Division of Allergy-Clinical Immunology, Johns Hopkins School of Medicine, Baltimore, Maryland
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9
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Blatman KSH, Capucilli P, Conway A, Shaker MS. The promise and power of patient partnerships and advocacy. Ann Allergy Asthma Immunol 2023; 131:687-688. [PMID: 38044018 DOI: 10.1016/j.anai.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 08/15/2023] [Indexed: 12/05/2023]
Affiliation(s)
- Karen S Hsu Blatman
- Section of Allergy and Clinical Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Peter Capucilli
- Allergy and Immunology, Rochester Regional Health, Rochester, New York; Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | | | - Marcus S Shaker
- Section of Allergy and Clinical Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
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10
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He Z, Tabe AN, Rana S, King K. Tirzepatide-Induced Biphasic Anaphylactic Reaction: A Case Report. Cureus 2023; 15:e50112. [PMID: 38186543 PMCID: PMC10771104 DOI: 10.7759/cureus.50112] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2023] [Indexed: 01/09/2024] Open
Abstract
Anaphylaxis is a rapid and severe reaction to a trigger that is characterized by skin, mucosal, and cardiorespiratory changes. A minority of patients exhibit a biphasic anaphylactic reaction (BAR). Tirzepatide is a dual incretin receptor analog approved for the treatment of type 2 diabetes mellitus (T2DM). Allergic reactions to tirzepatide were reported during clinical trials, but none were severe enough to be characterized as an anaphylactic reaction. We describe a case of a BAR to tirzepatide.
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Affiliation(s)
- Zhexiang He
- Internal Medicine, Conway Regional Medical Center, Conway, USA
| | - Agborya N Tabe
- Internal Medicine, Conway Regional Medical Center, Conway, USA
| | - Sohaib Rana
- Internal Medicine, Conway Regional Medical Center, Conway, USA
| | - Kristy King
- Internal Medicine, Conway Regional Medical Center, Conway, USA
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11
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Blumenthal KG, Greenhawt M, Phillips EJ, Agmon-Levin N, Golden DBK, Shaker M. An Update in COVID-19 Vaccine Reactions in 2023: Progress and Understanding. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3305-3318. [PMID: 37414339 DOI: 10.1016/j.jaip.2023.06.057] [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: 04/03/2023] [Revised: 05/24/2023] [Accepted: 06/26/2023] [Indexed: 07/08/2023]
Abstract
It has been 3 years since the coronavirus disease 2019 (COVID-19) pandemic was initially declared, and 2 years have passed since the first COVID-19 vaccines were introduced. Since then, 13.2 billion COVID-19 vaccine doses have been administered worldwide, largely with multiple doses of messenger RNA vaccines. Although mild local and systemic adverse effects after COVID-19 vaccination are common, serious adverse effects following immunization are rare, particularly when compared with the large number of vaccine doses administered. Immediate and delayed reactions are relatively common and present similarly to allergic and hypersensitivity reactions. Despite this, reactions generally do not commonly recur, cause sequelae, or contraindicate revaccination. In this Clinical Management Review, we provide an updated perspective of COVID-19 vaccine reactions, their spectrum and epidemiology, and recommended approaches to evaluation and management.
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Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; The Mongan Institute, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Matthew Greenhawt
- Department of Pediatrics, Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado Denver School of Medicine, Denver, Colo
| | - Elizabeth J Phillips
- Center for Drug Safety and Immunology, Departments of Medicine, Dermatology, Pharmacology, Pathology, Microbiology & Immunology, Vanderbilt University Medical Center, Nashville, Tenn
| | - Nancy Agmon-Levin
- The Clinical Immunology, Angioedema and Allergy Unit, Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Marcus Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH
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Shaker MS, Lieberman JA, Lang DM. Answering the Call for Trustworthy Clinical Guidelines. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3221-3222. [PMID: 37805225 DOI: 10.1016/j.jaip.2023.07.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 07/30/2023] [Indexed: 10/09/2023]
Affiliation(s)
- Marcus S Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, Dartmouth Geisel School of Medicine, Hanover, NH
| | - Jay A Lieberman
- Department of Pediatrics, The University of Tennessee Health Sciences Center, Memphis, Tenn
| | - David M Lang
- Department of Allergy and Clinical Immunology, Medical Specialty Institute, Cleveland Clinic, Cleveland, Ohio.
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13
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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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14
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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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15
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Abstract
PURPOSE OF REVIEW Systematic scoping review, focusing on randomized clinical trials of recent research addressing tree nut allergy. RECENT FINDINGS This review addresses published, unpublished, and re-analyzed studies on tree nut allergy definition, epidemiology, etiology, diagnosis, prognosis, and therapy. SUMMARY The importance of tree nut allergy spans nations, economies, and cultures. While broad themes in epidemiology, etiology, diagnosis, prognosis, and therapy are emerging, the next major advance in tree nut allergy will require large, robust studies to deliver results important to patients and families.
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16
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Chu DK, Golden DBK, Guyatt GH. Translating Evidence to Optimize Patient Care Using GRADE. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:4221-4230. [PMID: 34624540 DOI: 10.1016/j.jaip.2021.09.035] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 11/26/2022]
Abstract
Optimal evidence-based clinical practice requires systematic summaries of the best available evidence, including ratings of the quality of that evidence, and is facilitated by the availability of trustworthy guidelines. In this review, we describe the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to rating quality of evidence and moving from evidence to recommendations using examples from allergy-immunology. GRADE focuses on systematic summaries of the best evidence, systematic reviews and trustworthy guidelines, and emphasizes a structured approach to determining quality (certainty) of bodies of evidence, absolute magnitude of effects of desirable and undesirable consequences (benefits and harms), and use of evidence to develop clinical recommendations. Adopted by over 110 organizations worldwide, including the American Academy of Allergy, Asthma, and Immunology/American College of Allergy, Asthma, and Immunology Joint Task Force on Practice Parameters, GRADE is foundational to the optimal interpretation of research evidence and its application in clinical practice. This review supports the clinician's ability to find and use the information in GRADE guidelines to help care for patients in the clinic.
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Affiliation(s)
- Derek K Chu
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Research Institute of St. Joe's Hamilton, Hamilton, Ontario, Canada.
| | - David B K Golden
- Department of Medicine, Division of Allergy-Immunology, Johns Hopkins University, Baltimore, Md
| | - Gordon H Guyatt
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Abstract
PURPOSE OF REVIEW Epinephrine is the agreed-upon first line treatment for anaphylaxis, yet it continues to be underused by patients/caregivers and providers alike. RECENT FINDINGS There are unfortunately limited data on how epinephrine can best be utilized in anaphylaxis, which hinders how best to inform patients and providers. Studies reporting underuse suggest various barriers and themes on why this may happen. SUMMARY Continued education of patients, caregivers, and providers is needed; however, is not likely to be enough to close the gap. Thus, novel studies on how to increase use; increase availability in a cost-effective manner; and newer, effective delivery routes are still needed.
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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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19
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Reply to "Developing practice parameters that improve health of patients and populations". THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1047-1048. [PMID: 33551036 DOI: 10.1016/j.jaip.2020.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 12/03/2020] [Indexed: 11/24/2022]
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20
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Abrams EM, Singer AG, Greenhawt M, Stukus D, Shaker M. Ten tips for improving your clinical practice during the COVID-19 pandemic. Curr Opin Pediatr 2021; 33:260-267. [PMID: 33587368 PMCID: PMC8048379 DOI: 10.1097/mop.0000000000000998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW This review provides ten tips for improving clinical practice during COVID-19 as pandemic fatigue begins to complicate personal and professional lives of clinicians. RECENT FINDINGS COVID-19 has created unique and unexpected challenges to healthcare delivery, but has also provided opportunities for re-evaluation of practice patterns to optimize high-value practices. With ongoing uncertainty, key factors to appreciate for patient and population health include the continued touchstones of empathy and compassion, the use of effective risk communication with shared clinical decision-making when appropriate, attention to resource stewardship and vulnerable populations, importance of health literacy and need for critical assessment of media and medical literature to mitigate misinformation, and the hidden costs of the pandemic on children. Although there has been some international concern for allergic reactions to the recently approved Pfizer-BioNTech COVID-19 vaccine, neither the United States Pfizer-BioNTech or Moderna COVID-19 vaccine emergency use authorizations exclude patients without a specific allergy to a vaccine component from receiving vaccination. SUMMARY Practical adjustments to practice during COVID-19 are feasible and acceptable. Experience during COVID-19 reinforces the critical need for human connection while providing care and service in every encounter.
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Affiliation(s)
- Elissa M Abrams
- University of Manitoba, Department of Pediatrics, Section of Allergy and Clinical Immunology
| | - Alexander G Singer
- University of Manitoba, Department of Family Medicine, Winnipeg, Manitoba, Canada
| | - Matthew Greenhawt
- Children's Hospital of Colorado, University of Colorado School of Medicine, Department of Pediatrics, Section of Allergy and Immunology, Aurora, Colorado
| | - David Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Marcus Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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21
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Developing practice parameters that improve health of patients and populations. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1046-1047. [DOI: 10.1016/j.jaip.2020.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 12/03/2020] [Indexed: 02/01/2023]
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22
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Abrams EM, Singer AG, Shaker M, Greenhawt M. What the COVID-19 Pandemic Can Teach Us About Resource Stewardship and Quality in Health Care. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2021; 9:608-612. [PMID: 33253924 PMCID: PMC7691847 DOI: 10.1016/j.jaip.2020.11.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/21/2020] [Accepted: 11/12/2020] [Indexed: 12/29/2022]
Abstract
The coronavirus disease 2019 pandemic has forever changed how we view health care service delivery. Although there are undoubtedly some unintended consequences that will result from current health care service reallocation, it provides a unique opportunity to consider how to deliver quality care currently, and after the pandemic. In the context of lessons learned, moving forward some of what was previously routine could remain reserved for more exceptional circumstances. To determine what is "routine," what is "essential," and what is "exceptional," it is necessary to view medical decisions within the paradigm of high-quality care. The Institute for Healthcare Improvement definition of the dimensions of quality is based on whether the care is safe, effective, patient-centered, timely, efficient, and equitable. This type of stewardship has been applied to many interventions already deemed unnecessary by organizations such as the Choosing Wisely initiative, but the coronavirus disease 2019 pandemic provides a lens from which to consider other aspects of care. The following will provide examples from Allergy/Immunology that outline how we can reconsider what quality means in the post-coronavirus disease health care system.
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Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada.
| | - Alexander G Singer
- Department of Family Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Marcus Shaker
- Dartmouth-Hitchcok Medical Center, Section of Allergy and Immunology, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Matthew Greenhawt
- Department of Pediatrics, Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
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23
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Kaminski AE, Li Z, Dike NO, Gonzalez-Estrada A, Simon LV. Self vs partnered epinephrine autoinjector training, performance differences in an anaphylaxis simulation. Ann Allergy Asthma Immunol 2021; 126:304-306. [PMID: 33359453 DOI: 10.1016/j.anai.2020.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 11/24/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Ann E Kaminski
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida; Simulation Center, College of Medicine and Science, Mayo Clinic, Jacksonville, Florida.
| | - Zhuo Li
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - Nkechi O Dike
- Simulation Center, College of Medicine and Science, Mayo Clinic, Jacksonville, Florida; Division of Emergency Medicine, Department of Surgery, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Alexei Gonzalez-Estrada
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine Mayo Clinic, Jacksonville, Florida
| | - Leslie V Simon
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida
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24
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Greenhawt M, Shaker M, Wang J, Oppenheimer JJ, Sicherer S, Keet C, Swaggart K, Rank M, Portnoy JM, Bernstein J, Chu DK, Dinakar C, Golden D, Horner C, Lang DM, Lang ES, Khan DA, Lieberman J, Stukus D, Wallace D. Peanut allergy diagnosis: A 2020 practice parameter update, systematic review, and GRADE analysis. J Allergy Clin Immunol 2020; 146:1302-1334. [PMID: 32810515 DOI: 10.1016/j.jaci.2020.07.031] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/14/2020] [Accepted: 07/17/2020] [Indexed: 12/14/2022]
Abstract
Given the burden of disease and the consequences of a diagnosis of peanut allergy, it is important that peanut allergy be accurately diagnosed so that an appropriate treatment plan can be developed. However, a test that indicates there is peanut sensitization present (eg, a "positive" test) is not always associated with clinical reactivity. This practice parameter addresses the diagnosis of IgE-mediated peanut allergy, both in children and adults, as pertaining to 3 fundamental questions, and based on the systematic reviews and meta-analyses, makes recommendations for the clinician who is evaluating a patient for peanut allergy. These questions relate to when diagnostic tests should be completed, which diagnostic tests to utilize, and the utility (or lack thereof) of diagnostic testing to predict the severity of a future allergic reaction to peanut.
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Affiliation(s)
- Matthew Greenhawt
- Section of Allergy and Immunology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.
| | - Marcus Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Dartmouth Geisel School of Medicine, Lebanon, NH
| | - Julie Wang
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai and the Jaffe Food Allergy Institute, New York, NY
| | - John J Oppenheimer
- Department of Internal Medicine, New Jersey Medical School, Morristown, NJ
| | - Scott Sicherer
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai and the Jaffe Food Allergy Institute, New York, NY
| | - Corinne Keet
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md
| | - Keri Swaggart
- Library Services, Children's Mercy Hospital, Kansas City, Mo
| | - Matthew Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Ariz; Division of Pulmonology, Phoenix Children's Hospital, Phoenix, Ariz
| | - Jay M Portnoy
- Division of Allergy, Asthma & Immunology, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Mo
| | - Jonathan Bernstein
- Division of Immunology, Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Derek K Chu
- Department of Health Research Methods, Evidence & Impact, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; The Research Institute of St. Joe's Hamilton, Hamilton, Ontario, Canada
| | - Chitra Dinakar
- Division of Allergy and Asthma, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, Calif
| | - David Golden
- Department of Allergy-Clinical Immunology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Md
| | - Carolyn Horner
- Division of Allergy, Immunology, and Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo
| | - David M Lang
- Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Eddy S Lang
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David A Khan
- Division of Allergy & Immunology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Jay Lieberman
- Division of Allergy and Immunology, Department of Pediatrics, The University of Tennessee, Memphis, Tenn
| | - David Stukus
- Division of Allergy and Immunology, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Dana Wallace
- Nova Southeastern University College of Allopathic Medicine, Fort Lauderdale, Fla
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25
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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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26
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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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27
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Abrams EM, Shaker M, Oppenheimer J, Davis RS, Bukstein DA, Greenhawt M. The Challenges and Opportunities for Shared Decision Making Highlighted by COVID-19. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2020; 8:2474-2480.e1. [PMID: 32679348 PMCID: PMC7358768 DOI: 10.1016/j.jaip.2020.07.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/07/2020] [Accepted: 07/07/2020] [Indexed: 01/06/2023]
Abstract
Shared decision making (SDM) is a management paradigm that empowers patients as partners in their own care in a bidirectional exchange of information and values, and optimize the decision-making process. During the current coronavirus disease 2019 pandemic, there is a greater need to encourage participation in the SDM process. The pandemic has created both challenges and opportunities for delivering care, as system adaptations influence the physician-patient relationship. Although social distancing and health service reallocation can interfere with preference for an in-person visit, these measures also provide an avenue to study and implement virtual SDM processes. Communicating risk at a time of heightened uncertainty may pose a barrier to SDM engagement but provides the opportunity to foster a patient-centered approach within a more personalized context. Social media influence during coronavirus disease 2019 has resulted in an "infodemic" but highlights the importance of patient engagement. The pandemic has changed how we deliver care but allows us to re-evaluate common practices and enhance effectiveness of our management strategies. Navigating the uncertainty of subsequent pandemic waves creates confusion about how to safely reinitiate clinical service. This will require ongoing SDM with our patients and among colleagues through current-and future-challenges. Coronavirus disease 2019 has created many difficulties but has forced us to reexamine how to provide more patient-centered and high-quality care.
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Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada.
| | - Marcus Shaker
- Dartmouth-Hitchcok Medical Center, Section of Allergy and Immunology, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - John Oppenheimer
- UMDNJ Rutgers University School of Medicine and Pulmonary and Allergy Associates, Morristown, NJ
| | - Ray S Davis
- Division of Allergy, Immunology & Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo
| | - Don A Bukstein
- Allergy, Asthma, and Sinus Center, Milwaukee, Greenfield, Wis
| | - Matthew Greenhawt
- Department of Pediatrics, Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
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28
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Shaker M, Abrams EM, Greenhawt M. Clinician Adoption of US Peanut Introduction Guidelines-A Case for Conditional Recommendations and Contextual Considerations to Empower Shared Decision-Making. JAMA Netw Open 2020; 3:e2011535. [PMID: 32667650 DOI: 10.1001/jamanetworkopen.2020.11535] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Marcus Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Clinical Immunology, Lebanon, New Hampshire
- Department of Pediatrics, Medicine, and Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Matthew Greenhawt
- Department of Pediatrics, Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora
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29
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Castells MC. Drug allergy labeling and delabeling in the coronavirus disease 2019 era: What is important and what do we need to know. Ann Allergy Asthma Immunol 2020; 124:523-525. [PMID: 32448437 PMCID: PMC7242927 DOI: 10.1016/j.anai.2020.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/15/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Mariana C Castells
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, Boston, Massachusetts.
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30
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Casale TB, Wang J, Nowak-Wegrzyn A. Acute At Home Management of Anaphylaxis During the Covid-19 Pandemic. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1795-1797. [PMID: 32315792 PMCID: PMC7166008 DOI: 10.1016/j.jaip.2020.04.022] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/13/2020] [Accepted: 04/13/2020] [Indexed: 11/01/2022]
Affiliation(s)
- Thomas B Casale
- Food Allergy Research & Education (FARE), McLean, Va; Department of Medicine, Division of Allergy and Immunology, University of South Florida, Tampa, Fla.
| | - Julie Wang
- Jaffe Food Allergy Institute, Division of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Anna Nowak-Wegrzyn
- Allergy and Immunology, Department of Pediatrics, Hassenfeld Children's Hospital, New York University School of Medicine, New York, NY; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
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