What is the best approach to managing a case of allergy?

Approach to Managing a Case of Allergy

Establish a definitive diagnosis through detailed clinical history correlated with objective testing (skin prick tests or specific IgE), then implement a three-pronged treatment strategy: allergen avoidance, pharmacotherapy, and consideration of immunotherapy based on disease control and patient preference. 1

Initial Diagnostic Evaluation

Document specific clinical features:

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

Confirm diagnosis objectively:

• Perform skin prick testing or measure allergen-specific IgE antibodies 1
• For food allergy, use elimination-challenge testing to verify the offending food 2
• Remember that detection of food-specific IgE (sensitization) does not necessarily indicate clinical allergy; oral food challenges may be required for confirmation 3

Treatment Algorithm

First-Line Pharmacotherapy (for Allergic Rhinitis)

Intranasal corticosteroids are the most effective first-line treatment for persistent moderate-to-severe allergic rhinitis, used alone or combined with intranasal antihistamines. 1

• Start fluticasone propionate nasal spray 200 mcg once daily (2 sprays per nostril) in adults, or 100 mcg once daily (1 spray per nostril) in children aged 4 years and older 4
• Prescribe second-generation oral antihistamines over first-generation agents to avoid sedation and anticholinergic effects 1

Allergen Avoidance

Implement specific avoidance measures based on confirmed allergen sensitivities:

• Provide education on environmental control measures relevant to identified allergens 1
• For food allergy, strict dietary elimination is the most effective and inexpensive method 2
• Initially, dietary elimination may need to be strict, but certain patients may later tolerate limited quantities or certain preparations of the offending food without significant symptoms 2
• In breast-fed infants with food allergy, eliminate the offending food from the mother's diet 2

Emergency Preparedness (for Anaphylaxis Risk)

Provide self-injectable epinephrine and education on its use:

• Prescribe epinephrine auto-injector for patients at risk for anaphylaxis 5
• Educate patients to use epinephrine at the first sign of anaphylaxis symptoms and immediately call emergency services 5
• Advise patients and family members to routinely check the expiration date of the auto-injector 5
• Emphasize that patients are at risk for repeat episodes of anaphylaxis in the future 5

Immunotherapy Consideration

Offer allergen immunotherapy to patients with inadequate response to pharmacotherapy with or without environmental controls. 1

Specific indications include:

• Requiring high medication doses or multiple medications for disease control 1
• Experiencing adverse medication effects 1
• Wishing to avoid long-term medication use 1
• Stinging insect hypersensitivity at risk for anaphylaxis 1

Critical safety requirement:

• Asthma must be controlled at the time of immunotherapy administration 1

Choice of single vs. multiple allergen approach:

• In polysensitized patients (50-80% of those with moderate-to-severe respiratory allergies), single-allergen immunotherapy chosen according to the most clinically problematic allergy has robust evidence from large-scale trials 6
• Multiallergen immunotherapy can be clinically effective but requires more supporting data, particularly for sublingual routes and when using more than 2 allergen extracts 6

Special Considerations for Food Allergy

Adopt a patient and family-centered approach combining accurate diagnosis, emergency preparedness, and consideration of emerging immunotherapy options. 1

• Current immunotherapeutic strategies (OIT, EPIT, SLIT) are not without associated risk and remain experimental without FDA approval 5
• Patients with impaired quality of life at baseline improved significantly with oral immunotherapy despite burdensome demands, whereas some with acceptable quality of life at baseline had deterioration 5
• Most food-sensitive infants and young children will tolerate the offending food after 1-2 years of avoidance 2

Follow-Up and Monitoring

Arrange specialty consultation:

• Advise patients they may benefit from consulting an allergist for comprehensive evaluation 5
• Make efforts to identify the patient's trigger through history and follow-up testing before discharge from acute care 5
• Emphasize the importance of subsequent testing to determine and verify the trigger for successful future avoidance 5

Reassess treatment response:

• If no improvement within 48-72 hours of pharmacotherapy, consider resistance or misdiagnosis 7
• Monitor for psychological and behavioral impacts, particularly in children with food allergy, as these concerns correlate with parenting stress and quality of life 5