What are the latest guidelines for managing allergies, hypersensitivities, and chronic inflammation?

Latest Guidelines on Allergy, Hypersensitivities, and Chronic Inflammation

Diagnostic Approach

Diagnosis of allergic conditions requires demonstration of specific IgE antibodies through skin testing or in vitro testing that correlate with clinical symptoms and allergen exposure history. 1

• Skin prick testing is the preferred diagnostic method, with approximately 70-75% sensitivity compared to specific IgE immunoassays 1
• Select allergens for testing based on patient age, geographic location, occupation, and symptom timing—not random panels 1
• Positive allergy tests without correlation between allergen exposure and symptoms indicate nonallergic disease, even with positive IgE results 1
• Physical examination findings include pale edematous nasal mucosa in seasonal allergic rhinitis and erythematous inflamed turbinates in perennial disease 1, 2

First-Line Pharmacotherapy

For mild intermittent or mild persistent allergic rhinitis, initiate second-generation H1 antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) or intranasal antihistamines (azelastine, olopatadine). 2

For moderate-to-severe persistent allergic rhinitis, intranasal corticosteroids (fluticasone, triamcinolone, budesonide, mometasone) are first-line therapy, either alone or combined with intranasal antihistamines. 2, 1

Asthma Management

• Inhaled corticosteroids are the most consistently effective long-term control medication at all steps of care for persistent asthma and improve control more effectively than leukotriene receptor antagonists or any other single agent 1
• Long-acting beta-2 agonists serve as adjunctive therapy with inhaled corticosteroids for patients requiring step 3 or higher care 1
• Leukotriene receptor antagonists (montelukast, zafirlukast) are alternative but not preferred therapy for mild persistent asthma 1
• Short courses of oral systemic corticosteroids are used to gain prompt control, while long-term oral corticosteroids are reserved for severe persistent asthma requiring step 6 care 1

Critical Medication Warnings

• NSAIDs including naproxen should not be given to patients with aspirin triad (asthma, rhinitis, nasal polyps) as they can cause severe, potentially fatal bronchospasm 3
• Chronic use of oral or parenteral corticosteroids is inappropriate in allergic rhinitis; short courses may be used for intractable symptoms or severe nasal polyposis 1

Allergen Immunotherapy Indications

Allergen immunotherapy should be considered for patients with demonstrable specific IgE antibodies to clinically relevant allergens when symptoms remain inadequately controlled despite pharmacotherapy and avoidance measures. 1

Specific Criteria for Immunotherapy

• Patients requiring high medication doses, multiple medications, or experiencing adverse medication effects 1, 4
• Those wishing to avoid long-term pharmacotherapy 1, 4
• Immunotherapy is effective for pollen, animal allergens, dust mite, mold/fungi, and Hymenoptera hypersensitivity (Strength A recommendation) 1
• Plan for minimum 3 years of treatment for optimal clinical benefit and disease modification, including prevention of new sensitizations 1, 4

Contraindications and Precautions

• Ensure asthma is well-controlled before initiating immunotherapy injections—uncontrolled asthma is a contraindication 4
• Do not administer immunotherapy to patients with negative specific IgE tests or positive tests that do not correlate with clinical symptoms 1
• Clinicians administering omalizumab (anti-IgE) must be prepared and equipped to identify and treat anaphylaxis 1

Management of Comorbid Conditions

Upper Airway Disease

• Evaluate and treat rhinitis or sinusitis in all asthma patients, as upper airway therapy improves asthma control 1
• Treatment of allergic rhinitis includes intranasal corticosteroids, antihistamines, and consideration of immunotherapy 1
• Treatment of sinusitis includes intranasal corticosteroids and antibiotics 1

Chronic Rhinosinusitis

• Refer patients with chronic rhinosinusitis to allergist-immunologists, as specialist care is associated with improved outcomes 1
• Chronic eosinophilic rhinosinusitis often coexists with aspirin sensitivity, asthma, and sinus-nasal polyposis 1
• Allergic fungal rhinosinusitis requires evaluation with allergy skin testing and management with pharmacotherapy, immunotherapy, and surgery 1

Weight and Sleep Management

• Obese or overweight asthma patients should be advised that weight loss may improve asthma control in addition to overall health 1
• Consider obstructive sleep apnea in patients with poorly controlled asthma, particularly those who are overweight or obese 1
• Treatment for OSA is nasal continuous positive airway pressure, but accurate diagnosis is important as it may disrupt sleep in asthma patients without OSA 1

Anaphylaxis Management

Epinephrine is the only first-line treatment for anaphylaxis—there is no substitute. 1

• Administer intramuscular epinephrine in the anterolateral thigh (vastus lateralis muscle) rather than subcutaneous injection for more rapid plasma concentrations 1
• 10-20% of individuals require more than one dose of epinephrine; repeat dosing every 5-15 minutes as needed for ongoing or progressive symptoms 1
• Antihistamines are not a substitute for epinephrine and their use is the most common reason for failing to administer epinephrine, placing patients at significantly increased risk 1
• H1 and H2 antihistamines and corticosteroids are adjunctive only, with little data demonstrating effectiveness in anaphylaxis 1

Urticaria and Angioedema

• Refer patients with acute urticaria or angioedema without obvious trigger to allergist-immunologist for comprehensive evaluation including history, physical examination, skin testing, in vitro testing, and challenges when indicated 1
• Refer patients with chronic urticaria or angioedema (lesions recurring >6 weeks) to allergist-immunologist or dermatologist for specialized management 1
• Chronic urticaria often has autoimmune pathogenesis requiring expert evaluation 1

Allergen Avoidance Strategies

Avoidance of allergen triggers is fundamental to successful management and should always be attempted, even though complete avoidance is rarely possible. 1, 5

• Early administration of medications before anticipated allergen exposure or symptom development may lessen impact 1
• Allergen avoidance requires several days to weeks to be effective 5
• For house dust mite allergy, use mite allergen-proof mattress encasings and washable blankets; reassess after 3 months of avoidance measures 1

Referral Criteria to Allergist-Immunologist

• Patients with inadequate response to pharmacotherapy with or without environmental controls 1
• Children with allergic rhinitis for potential preventive role of immunotherapy in reducing new sensitizations and asthma development 1
• Patients with nasal polyps requiring specialized medical management 1
• Patients with suspected immunodeficiency, cystic fibrosis, fungal sinusitis, or granulomatous diseases 1

Common Pitfalls to Avoid

• Do not use IgG antibody testing to identify allergen triggers—allergic rhinitis is IgE-mediated and only specific IgE testing (skin or blood) is appropriate 4
• Do not assume all positive allergy tests are clinically relevant; up to 54% of the general population tests positive on skin prick tests without clinical disease 4
• Do not delay epinephrine administration in anaphylaxis—failure to administer early has been repeatedly implicated in fatalities 1
• Do not use inhaled corticosteroids alone for acute asthma exacerbations—systemic corticosteroids are required for moderate-to-severe cases 6
• Do not give NSAIDs to patients with aspirin-sensitive asthma (aspirin triad) due to risk of severe bronchospasm 3