Referral of Severe Allergies with Autoimmune Considerations
Patients with severe allergies, particularly those with suspected autoimmune components, should be referred to a board-certified allergist-immunologist for comprehensive evaluation, diagnostic testing, and management. 1
Who to Refer to an Allergist-Immunologist
An allergist-immunologist is a physician trained in internal medicine or pediatrics who has completed an additional 2+ years of specialized training in allergy and immunology at an accredited program. 1 These specialists are uniquely qualified to:
- Perform and interpret allergy testing (skin tests, in vitro specific IgE studies) 1, 2
- Evaluate immune competence and identify primary immunodeficiency 1
- Provide immunomodulator therapy (anti-IgE, intravenous immunoglobulin) 1
- Conduct drug desensitization and food/drug challenges 1
- Manage complex cases where allergy and autoimmune features overlap 1
Specific Indications for Referral
Severe Allergic Reactions
- Anaphylaxis without obvious trigger: Requires comprehensive evaluation by an allergist-immunologist to identify the specific cause through skin testing, in vitro tests, and challenges when indicated. 1
- Recurrent anaphylaxis: Management by an allergist-immunologist is associated with reduced hospitalizations and emergency department visits. 1
Suspected Immune Dysfunction
- Recurrent or unusual infections (≥8 new infections/year, ≥2 serious sinus infections/year, ≥2 pneumonias/year, or >2 months on antibiotics with little effect): These warning signs suggest primary immunodeficiency requiring advanced diagnostic strategies. 1
- Chronic rhinosinusitis with recurrent infections: Many patients have underlying humoral immunodeficiency that requires evaluation. 1
Complex Allergic Disease
- Allergic bronchopulmonary aspergillosis (ABPA): Requires specialized allergen skin testing and in vitro tests correlated with clinical findings for diagnosis, and allergist-immunologists are specifically trained to manage this condition. 1
- Severe asthma with allergic rhinitis: Combined aggressive management including potential allergen immunotherapy improves outcomes. 1
- Chronic urticaria-angioedema, eczema, or other conditions where allergy is not clearly identified: Allergist-immunologists manage these chronic conditions where immune dysregulation may play a role. 1
Evidence Regarding Autoimmune Concerns
Importantly, allergen-specific immunotherapy (when indicated) is associated with a lower risk of autoimmune disease development, not higher. 3 A large registry study of 18,841 patients receiving subcutaneous immunotherapy showed:
- Reduced incidence of autoimmune disease (HR 0.86,95% CI 0.74-0.99) 3
- Lower all-cause mortality (HR 0.71,95% CI 0.62-0.81) 3
- Decreased acute myocardial infarction risk (HR 0.70,95% CI 0.52-0.93) 3
While historical case reports raised concerns about immunotherapy triggering autoimmune disease, large-scale evidence demonstrates the opposite effect. 3, 4
Type of Referral Needed
The referral may take different forms depending on severity: 1
- Single consultation: For diagnostic clarification or treatment recommendations
- Co-management: Coordinated care between primary provider and allergist-immunologist
- Ongoing specialty care: For complex cases requiring continuous specialized management
Critical Pitfalls to Avoid
- Delaying referral for anaphylaxis: Patients with severe allergic reactions should be referred promptly for trigger identification and prevention strategies. 1
- Missing immunodeficiency: Recurrent infections in the context of "allergies" may represent primary immunodeficiency requiring immunologic therapy. 1
- Assuming autoimmune disease precludes allergy evaluation: The two conditions can coexist, and proper allergy management may actually reduce autoimmune risk. 3
- Ordering allergy testing without clinical correlation: Testing should only be performed by or under supervision of qualified specialists who can interpret results in clinical context. 2