What is the approach to managing a patient with an allergy?

Approach to Managing the Allergy Patient

The cornerstone of allergy management is establishing a definitive diagnosis through detailed clinical history correlated with objective testing (skin prick testing or serum-specific IgE), followed by a three-pronged treatment strategy: allergen avoidance, pharmacotherapy, and consideration of immunotherapy based on disease control and patient preference. 1, 2

Initial Diagnostic Evaluation

Clinical History and Symptom Assessment

• Document specific symptoms: nasal congestion, rhinorrhea, nasal pruritus, sneezing, ocular symptoms, respiratory symptoms, or systemic reactions 2
• Establish temporal relationship between symptoms and suspected allergen exposure 1, 2
• Assess symptom severity, frequency, and impact on quality of life 1
• Identify previous treatments attempted and their effectiveness 1

Confirmatory Testing Strategy

Skin prick testing is the preferred initial diagnostic method due to superior simplicity, rapid results, low cost, and high sensitivity compared to serum IgE testing. 2, 3

• Perform skin prick/puncture tests as first-line testing for suspected IgE-mediated allergies 2, 4
• Reserve serum-specific IgE testing for situations where skin testing is contraindicated or impractical 2, 3
• Test only for allergens that correlate with clinical history and exposure patterns 1

Critical caveat: Positive testing (skin or serum IgE) indicates only sensitization, not necessarily clinical allergy—symptoms must correlate with exposure for diagnosis. 5, 4

Treatment Algorithm

First-Line Pharmacotherapy

For persistent moderate-to-severe allergic rhinitis, intranasal corticosteroids are the most effective first-line treatment, used alone or combined with intranasal antihistamines. 2

• Prescribe second-generation oral antihistamines over first-generation agents to avoid sedation and anticholinergic effects 2
• Avoid leukotriene receptor antagonists as primary monotherapy 2

Allergen Avoidance

• Implement specific avoidance measures based on confirmed allergen sensitivities 1
• Provide education on environmental control measures relevant to identified allergens 1

Immunotherapy Consideration

Offer allergen immunotherapy to patients with inadequate response to pharmacotherapy with or without environmental controls. 2

Additional appropriate candidates include: 1

• Patients requiring high medication doses or multiple medications for disease control
• Those experiencing adverse medication effects
• Patients wishing to avoid long-term medication use
• Individuals with stinging insect hypersensitivity at risk for anaphylaxis

Essential prerequisite: Asthma must be controlled at the time of immunotherapy administration. 1

When NOT to Pursue Immunotherapy

Do not offer immunotherapy to patients with: 1

• Negative specific IgE testing
• Positive IgE tests that don't correlate with clinical symptoms or exposure
• Uncontrolled asthma at time of administration

Emergency Management Preparation

All patients with confirmed IgE-mediated allergies at risk for anaphylaxis must be prescribed epinephrine auto-injectors. 6

• Dosing: Adults and children ≥30 kg: 0.3-0.5 mg IM; children <30 kg: 0.01 mg/kg (maximum 0.3 mg) 6
• Inject intramuscularly into anterolateral thigh, repeatable every 5-10 minutes as necessary 6
• Provide patient education on recognition of anaphylaxis and proper auto-injector technique 1

Special Considerations

Food Allergy Management

The integrated model for food allergy care emphasizes patient and family-centered approaches combining accurate diagnosis, emergency preparedness, and consideration of emerging immunotherapy options. 1

• Elimination diet is initial treatment for suspected food allergens 7
• If elimination ineffective, proceed with IgE-specific antibody or skin testing 7
• Oral food challenge confirms diagnosis when testing is equivocal 7

Drug Allergy Evaluation

• Penicillin skin testing has high negative predictive value and should be performed when penicillin is indicated with limited alternatives 1, 7
• Direct oral challenge may be appropriate for low-risk patients with non-severe, non-IgE-mediated histories 1
• Testing for other drug allergies has less established sensitivity/specificity but can guide diagnosis 7

Contact Dermatitis

• Patch testing identifies allergens responsible for delayed (Type IV) hypersensitivity reactions 3, 7

Common Pitfalls to Avoid

• Never diagnose allergy based solely on positive testing without correlating clinical symptoms 5, 4
• Do not test for allergens unrelated to patient's exposure history or symptoms 1
• Avoid administering immunotherapy when asthma is uncontrolled 1
• Do not confuse sensitization (positive test) with clinical allergy (symptoms with exposure) 5, 4