The Revenge of Unintended Consequences of Anaphylaxis-Risk Overdiagnosis: How Far We Have Come and How Far We Have to Go

Food Allergy, Nutrition, Psychology, and Health

This article explores food allergy and the nascent field of nutritional psychiatry. Individuals with food allergy experience lower levels of "food freedom" than their nonallergic counterparts, which can create cognitive, emotional, social, nutritional, and financial burdens. Patterns of food avoidance may influence neuroinflammatory states and the gut microbiome; these changes may be associated with neuropsychiatric symptoms. Food restriction may promote disruption of the microbiome neuroimmune axis, which has been linked to various allergic diseases. Targeted psychological counseling strategies can provide benefit. Food allergy and restricted diets may impact dietary health benefits.

Possible Resolution of Food Allergies Following Tocilizumab-Induced Remission of Juvenile Idiopathic Arthritis

This case report describes a unique instance of a four-year-old Ashkenazi Jewish male with systemic juvenile idiopathic arthritis (JIA) and severe IgE-mediated food allergies who achieved complete remission of both conditions following treatment with tocilizumab, an IL-6 receptor antagonist. The patient initially presented with anaphylactic reactions to peanuts, eggs, and cow's milk, confirmed by positive skin prick tests and elevated specific IgE (sIgE) levels. Systemic JIA symptoms, including daily fever spikes, evanescent rash, and polyarticular arthritis, developed shortly thereafter. After inadequate response to standard therapies, tocilizumab was initiated, resulting in complete remission of JIA symptoms and unexpected resolution of food allergies. Repeat allergological evaluations, including skin prick tests, sIgE levels, and controlled oral food challenges, confirmed sustained tolerance to previously allergenic foods. The dual remission observed in this case suggests that interleukin-6 (IL-6) inhibition may modulate shared immunological pathways underlying autoimmune and allergic diseases. IL-6 is a key cytokine in both conditions, promoting Th17-mediated inflammation in JIA and Th2-mediated allergic responses, including IgE production and mast cell activation. While the spontaneous resolution of food allergies, particularly to milk and eggs, is well-documented in pediatric populations, the resolution of peanut allergy, in this case, is highly unusual and temporally associated with tocilizumab treatment. This case raises the possibility that IL-6 inhibition may play a role in modulating autoimmune and allergic responses, warranting further investigation into the interplay between these pathways.

Pearls for practice from the 2023 joint task force anaphylaxis practice parameter

PURPOSE OF REVIEW

To share important highlights on the management of anaphylaxis from the latest 2023 practice parameter.

RECENT FINDINGS

The 2023 Allergy Immunology Joint Task Force on Practice Parameters (JTFPP) anaphylaxis practice parameter provides updated anaphylaxis guidance. Criteria for the diagnosis of anaphylaxis are reviewed. The parameter highlights that while anaphylaxis is not more severe in younger children, age-specific symptoms can vary. Activation of emergency medical services may not be required in patients who experience prompt resolution of symptoms following epinephrine use and caregivers are comfortable with observation. For children weighing <15 kg, the anaphylaxis parameter suggests the clinician may prescribe either the 0.1 mg or the 0.15 mg epinephrine autoinjector, with the 0.3 mg autoinjector prescribed for those weighing 25 kg or greater. In patients with heart disease, discontinuing or changing beta blockers and/or angiotensin converting enzyme inhibitors may pose a larger risk for worsened cardiovascular disease compared with risk for severe anaphylaxis with medication continuation. Furthermore, in patients with a history of perioperative anaphylaxis, shared decision-making based on diagnostic testing and clinical history is recommended prior to repeat anesthesia use. Beyond the recent parameter update, novel contemporary therapies can decrease risk of community anaphylaxis.

SUMMARY

The 2023 JTFPP Anaphylaxis Guidelines offer up-to-date guidance for the diagnosis and management of anaphylaxis in infants, children, and adults.

A Media Advocacy Toolkit for the Allergist-Immunologist

For clinicians involved in improving healthcare for patients with allergic and immunologic conditions, advocacy on a broader level through public outreach is key to advancing value-based care. In this article, we provide a toolkit of strategies and resources that can be used to raise public awareness of important issues through various mediums, including podcasts and social media, newspapers, testimonies, presentations, and interviews. A simple approach to effective media interactions is described using the acronym "RATIO," which stands for Research, Audience, Targeted topic, Interview rephrasing, and Optimism. The acronym also reminds the person who is presenting information that only a fraction of what is discussed will be recalled, and an even smaller proportion will be implemented. Key points should be made early. Examples of key talking points are provided for selected topics, including food allergy, anaphylaxis, asthma, rhinitis, and broader healthcare advocacy.

Food allergy prevention through the decades: An ounce of humility is worth a pound of cure

Food allergy prevention has undergone a significant transformation over the past 3 decades. This review provides an overview of the evolution of food allergy prevention, highlighting changes in guidance, cost-effectiveness of prevention, the role of shared decision-making, and the emergence of oral immunotherapy for those in whom primary prevention fails. Changes to food allergy prevention over recent decades can be conceptualized into five epochs, which have followed a general trend of loosening restrictions on the allergen introduction timeline. These epochs are characterized by significant maternal and infant dietary restrictions in the "universal avoidance epoch"(-1990), loosened maternal diet restrictions in the "infant avoidance epoch" (1990-2000), a time-bound allergen introduction schedule in the "stratified avoidance epoch" (2000-2010), retraction of recommendations in the "corrective retraction epoch" (2010-2015), and endorsement of early allergen introduction in the "early introduction epoch" (2015-present), the start of which is marked by the 2015 Learning Early About Peanut study. In hindsight, it is clear that certain recommendations from previous decades were not the best course of action. A no-screening early introduction approach to food allergy prevention is both cost-effective and beneficial to patient quality of life.

Beyond Confirmed Mast Cell Activation Syndrome: Approaching Patients With Dysautonomia and Related Conditions

Allergist-immunologists face significant challenges as experts in an ever-evolving field of neuroimmunology. Among these challenges is the increasingly frequent need to counsel patients with suspected mast cell activation disorders about perceived comorbidities, which may include hypermobile Ehlers-Danlos syndrome, amplified pain syndrome, fibromyalgia, burning sensation syndromes, migraines, irritable bowel syndrome, and postural orthostatic tachycardia syndrome. Patients may experience comorbid anxiety, panic disorder, and depression associated with disturbed sleep, fatigue, and cognitive impairment that often worsen when their physical symptoms increase in severity. These conditions may mimic mast cell activation disorders and are emotionally taxing for patients and clinicians because they are often accompanied by vague diagnostic courses, perceived unmanageability, social stigma, and significant impairment in quality of life. Combined with relatively poorly researched therapies, it is no surprise that clinicians may feel overwhelmed or find it difficult to provide consistently compassionate care for this population. In this article, we review available therapies for these conditions, which run the gamut from physical therapy to antidepressants to multimodal pain control. We highlight the benefit of multidisciplinary care within the primary care home, which includes an important role by the allergist-immunologist. By outlining simple approaches to initial treatment, we hope to empower clinicians with the tools needed to curb emotional burnout and embrace this patient population with compassion.

Serologic measurements for peanut allergy: Predicting clinical severity is complex

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.

Pharmacoequity and Biologics in the Allergy Clinic: Providing the Right Care, at the Right Time, Every Time, to Everyone

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.

Fruitful or unfruitful: strawberry and tomato specific immunoglobulin E testing at a tertiary pediatric center

Background

Suspected strawberry and tomato (S/T) food allergy (FA) can be evaluated using specific immunoglobulin E (sIgE) testing despite its low specificity and positive predictive value.

Objective

This study aims to understand ordering patterns for S/T sIgE testing and identify relevant factors to clinical decision-making.

Methods

We retrospectively reviewed 814 patients with sIgE testing available for strawberries (651), tomatoes (276), or both (113) from January 2012 to May 2022 at a tertiary pediatric hospital. Patient demographics, provider specialty, and reasons for testing were collected. Student's t-test and multiple regression analyses were performed to test the association between the S/T sIgE level and clinically relevant outcome (CRO) status. Fisher's exact test and general linear models were used to evaluate and compare potential predictive factors for CRO status.

Results

Allergy and immunology, gastroenterology, and general pediatrics ordered most S/T sIgE testing. Testing was ordered most frequently for non-IgE-mediated gastrointestinal symptoms, mild possible IgE-mediated reactions, and eczema. Testing was most often ordered for infants and school-age children. Mean sIgE levels were higher for S/T tests resulting in a CRO when controlling for other predictor variables (p = 0.015; p = 0.002 for S/T, respectively). Only 2.2% and 5.4% of tests resulted in a CRO for S/T, and severe allergy was rare. Testing for non-IgE-mediated GI symptoms or eczema, or in non-atopic patients, yielded no CROs. Exposure and reaction history of present illness (ERH) was associated with CROs (p < 0.001; p = 0.04) with a high negative predictive value (99.5%; 100%) and low positive predictive value (11.5%; 15.0%). ERH (p < 0.001, η2 = 0.073; p = 0.009, η2 = 0.123) was a more significant predictor than the sIgE level (p = 0.002, η2 = 0.037; p = 0.212, η2 = 0.030) for CRO status.

Conclusion

The diagnosis of S/T food allergy is made primarily based on clinical history. S/T sIgE testing for children and adolescents should be avoided for patients without an ERH and in the workup of non-IgE-mediated GI symptoms. Testing for eczema and non-atopic patients is likely low-yield.

Provision of Food Allergy Care in the United Kingdom and United States: Current Issues and Future Directions

Food allergy (FA) is a growing issue worldwide. The United Kingdom and United States are high-income, industrialized countries with reported increases in FA prevalence over the past few decades. This review compares delivery of FA care in the United Kingdom and United States and each country's response to the heightened demand and disparities for FA services. In the United Kingdom, allergy specialists are scarce and general practitioners (GPs) provide most allergy care. Whereas the United States has more allergists per capita than the United Kingdom, there is still a shortage of allergy services owing to the greater reliance on specialist care for FA in America and wide geographic variation in access to allergist services. Currently, generalists in these countries lack the specialty training and equipment to diagnose and manage FA optimally. Moving forward, the United Kingdom aims to enhance training for GPs so they may provide better quality frontline allergy care. In addition, the United Kingdom is implementing a new tier of semi-specialized GPs and increasing cross-center collaboration through clinical networks. The United Kingdom and United States aim to increase the number of FA specialists, which is critical at a time of rapidly expanding management options for allergic and immunologic diseases requiring clinical expertise and shared decision-making to select appropriate therapies. While these countries aim to grow their supply of quality FA services actively, further efforts to build clinical networks and perhaps recruit international medical graduates and expand telehealth services are necessary to reduce disparities in access to care. For the United Kingdom in particular, increasing quality services will require additional support from the leadership of the centralized National Health Service, which remains challenging.

Acute At-Home Management of Anaphylaxis: 911: What Is the Emergency?

The appropriate at-home management of anaphylaxis begins with patient education on recognition and treatment, especially when and how to use epinephrine. Delayed administration of epinephrine as well as having severe symptoms and needing multiple doses of epinephrine to treat symptoms are risk factors for biphasic anaphylaxis. The successful implementation of at-home management of anaphylaxis requires appropriate patient selection and an algorithmic approach that recommends activation of emergency medical services (EMS) when the patient does not adequately respond to at-home administration of epinephrine or there are extenuating patient-related circumstances. Fortunately, approximately 98% of anaphylactic episodes respond to 2 or fewer doses of epinephrine, the standard prescription used for epinephrine autoinjectors; fatal anaphylaxis is very rare, as low as 0.002 deaths/million person-years; and biphasic reactions are uncommon (∼5%), and only extremely rarely lethal. Thus, most common concerns leading to recommended EMS activation and emergency department visits after epinephrine administration are generally unsubstantiated. Furthermore, emergency department visits do not always lead to better treatment and drive health care costs higher. Open communications with patients and families regarding risks and benefits of at-home management and observation versus EMS activation and emergency department evaluation after epinephrine administration for anaphylaxis are essential. However, we believe the data indicate that it is time to reconsider the often used and taught approach that recommends EMS activation whenever epinephrine is used.

Overdiagnosis in the emergency department: a sharper focus

Overdiagnosis occurs when a person's symptoms or life experiences are given a diagnostic label that ultimately causes them more harm than good. We describe the complex drivers of overdiagnosis spanning five interconnected domains, which can lead to numerous negative impacts on patients. Emergency physicians are often tasked with making timely clinical assessments, decisions, and diagnoses that can unintentionally result in overdiagnosis. Three pertinent areas related to overdiagnosis in Emergency Medicine: anaphylaxis, subsegmental pulmonary embolism, and low-risk chest pain are discussed. For a broader perspective, insight on overdiagnosis from medical students and a patient advisor are presented. The perspectives illustrated are meant to spark reflection on: the ethics of labeling a person with a diagnosis, current clinical practices, the limitations of medical education, and patient care and communication in the context of overdiagnosis in the Emergency Department.