Reciprocal effects of age and clinical allergy: is there more to be learned?

Oral challenges are needed in the diagnosis of beta-lactam hypersensitivity

BACKGROUND

beta-lactams continue to remain the most commonly involved drug family in allergic drug reactions. They are often essential and there is a cost-effective and favourable risk-benefit ratio for the exploration of all suspicions of beta-lactam allergy. A firm diagnosis is always based on skin tests and sometimes on provocation tests. Recommendations have been published by allergy societies and distinguished scientists but they are not always concordant and can lead to some confusion for the practicing allergologist. The situation has even worsened since the world wide withdrawal of these penicillin determinants and since the predominance of amoxicillin and cephalosporin prescriptions in most countries. OBJECTIVE - METHOD: In a recent article, it was stated that patients with a penicillin allergy history and negative skin tests to major and minor penicillin determinants are at a low risk of relapse (0-5%) when receiving a beta-lactam. In this paper, our Drug Allergy and Hypersensitivity Database, a cohort database, was used to demonstrate that this statement is false. Standardized European Network for Drug Allergy questionnaires, skin test and challenge procedures were followed.

RESULTS

One-thousand two-hundred and eighteen subjects, 69.8% of female, 51.7% of atopics, were included. 21.1% had a true beta-lactam allergy confirmed by skin tests (178, 69.3%) or by drug provocation (79, 30.7%). 17.4% of the patients with negative skin tests to major and minor penicillin determinants were positive for a beta-lactam.

CONCLUSION

In the diagnosis of beta-lactams allergy, if all skin tests are negative, skin tests with other determinants and provocation tests under strict surveillance are mandatory.

Allergen prick-puncture skin testing in the elderly

Many older patients present with rhinitis, conjunctivitis, asthma or itching that the patient attributes to allergies. Yet physicians often dismiss allergy in the elderly as irrelevant. Testing elderly patients for allergies is sometimes challenging as changes in the skin may cause difficulty in applying skin tests, and the response of the skin may be difficult to measure. The prick puncture skin test is the preferred method of immediate-type allergy testing, but careful examination of the skin prior to skin testing is important. If the area of skin where allergen skin tests are routinely placed is either atrophic or severely sun damaged, a sun-protected area should be sought. If no suitable area of skin can be identified, in vitro allergen testing should be considered. Skin-test results must be interpreted with care in the elderly. Positive skin tests to an allergen must correlate with a history of exacerbation to the allergen. By identifying specific allergens to which the elderly patient is sensitive, avoidance measures or specific allergen vaccination can be recommended, improving the quality of life and decreasing the need for medications.

Survey of the extent and nature of care for adults and older adults by allergy/immunology practitioners

BACKGROUND

The proportion of older adults in the US population will increase dramatically in the near future, yet the frequency and nature of care furnished to older adults by Allergy/Immunology practitioners has not been described.

OBJECTIVE

To determine the extent and nature of care being provided to adults and older adults by Allergy/Immunology practitioners.

METHODS

ACAAI members and fellows were surveyed to obtain information regarding certification and training as well as their practice patterns.

RESULTS

The distribution of diagnoses among patients aged 40 to 54 years were very similar to distributions found among adults age 55 to 69 years and > or = 70 years of age. Virtually all respondents indicated they provide inhalant allergen immunotherapy for patients age 40 to 54 years with asthma and/or allergic rhinitis; administration of inhalant allergen immunotherapy for asthma and allergic rhinitis was also frequently reported for adults > or = 55 years. The proportions of respondents providing venom immunotherapy for adults aged 40 to 54, 55 to 69, and > or = 70 years were 82%, 70%, and 39%, respectively.

CONCLUSION

ACAAI members and fellows commonly provide care to older adults. Our survey findings highlight the need to develop strategies for successful management of Allergy/Immunology conditions specifically pertaining to older adults, including studies to determine the therapeutic utility of inhalant allergen and venom immunotherapy in this age group.