This breakdown of common allergies provides clarity on which patients to test and which tests to choose; how to effectively manage chronic allergies, such as allergic rhinitis; as well as signs and solutions for the many types of adverse food reactions.
me. I tried to hit some of the things that I thought were things I learned in my fellowship that are super helpful when I think about treating patients with allergies. So the few things that I thought would be sort of most important to review our one in general, the process of allergy testing. So the learning objective here is to describe indications for allergy testing. But we'll talk through sort of what RG testing is and when we consider it for patients. Um, second in allergic rhinitis. I know this is a common thing you see pretty much pretty frequently and has been a lot worse, I think, in general this year, with people staying indoors, more being exposed to more dust fights. Um, certainly the pollen seasons are getting worse over time. We have definitely seen that. And with the smoke that's also been aggravating things for patients. And so to summarize how I think about the best practices for what I usually go reach for first to treat patients with chronic rhinitis symptoms, um, then to talk about food allergies and thio, identify and describe different types of adverse food reactions, Um, then talk about drug allergy and most specifically, penicillin allergy. Because that is one way that we think that we as allergist can really help treat a patient overall very well. UM, is to remove their penicillin allergy if they're no longer penicillin, allergic on Ben finally, just to go through some causes of acute and chronic or to carry a. Since that's a common thing I know you see and that you do refer to an allergist so first talking about allergic testing. So allergy testing is helpful for conditions that are affected by specific allergens, so that includes allergic rhinitis, asthma, food allergies, izmery topic dermatitis, drug allergies and venom allergy. So if a patient has a history that's concerning or consistent with an allergic reaction, an allergy testing could be helpful to identify the presence of specific I G. So that in part, is what I first would like, Thio point out to patients is that allergy testing is for allergy antibody. So we really recommend allergy testing on Lee if we think the problem is related to an allergy antibody. But it can be very, very helpful for patients, and it can help identify specific triggers. So we know to direct how to directed optimize their management. Um, that means that you know, if someone is dust mite allergic, then I can recommend that they use dust mite allergy covers. Um, if someone is tree allergic, then I can recommend the that they take their medicines during the season that that tree would be pollinating, so it can very much help. Ah, lot of patients understand, even if they don't necessarily go on to do immunotherapy or, um, you know, need other things from us specifically. Often, I will say patients one time, and just that they understand what their specific triggers are and to is if they are interested in allergen immunotherapy, whether that's we'll talk about their different forms, there's either subcutaneous or shots or sublingual, which is like a tablet that they take, um, those all require that they are specifically allergic to something, so we do need to document it for that for those therapies. So again, allergy testing is for allergy antibody or I g E. And these tests are confirmatory diagnostic tool that reflects sensitization and doesn't make the diagnosis of clinical allergy. So this is important because history alone isn't enough to diagnose someone with, you know, a specific allergy. Um, but at the same time, testing alone is not enough to diagnose someone with an allergic disease. To really have a clinical allergy, you have to have a history and the confirmatory allergy tests. So there are two main ways that we do. Allergy testing for allergy antibody one is with skin prick testing. And then the other way is with basic lobotomy, which checks for specific I g antibody eso skin prick testing. I like to explain it to patients that it's called a prick, but it's more like a poke with a sharp object because it doesn't actually draw any blood on DSO. We take thes little devices that have the, uh, allergens that they could be allergic to and then poke their skin with it. And that part doesn't actually bother them so much. It's the next 15 minutes. They can't hitch their skin because then that just, um, spreads all the allergies that we can't tell what they're allergic to specifically. So they have to sit there for 15 minutes and not teach their arm, which, honestly, is the worst part of it. But it is relatively fast 15 minutes later, we can actually read it, figure out what somebody is allergic to. So the whole process only takes about 30 minutes to an hour to figure out what somebody could be allergic to, which is really, really nice specific allergy and a body is something that I have been testing a lot more. I think, in the setting of coronavirus where patients don't necessarily want to come in person. And, um, it can actually be pretty useful. And depending on the type of allergy in which we'll talk about is very, very reliable as well. And this is a simple blood draw. So some patients prefer that in some patients I prefer the skin prick testing. Um, in general, we think that skin prick testing is more sensitive and then specific. IgG antibody is maybe a little bit more specific. But both of them honestly can be reliable, depending on the type of allergies that we're looking at. So we will often utilized both of these tests, um, for a number of different things. There are other factors that obviously come into play, so skin protesting involves testing the skin specifically, so the skin that somebody where we're testing needs to be uninvolved. The areas that we use are either the arms, the inside of the arms or the upper back. So those two areas need to be uninvolved skin, one of the two, honestly. But I've had patients who, unfortunately, had a patient who came in and unfortunate tattoos all over their body, and so we weren't able to do it there. Also, someone has very bad eczema in all those areas. That would be another reason. Often we aren't able to do it. If somebody is dramatic graphic where if we, you know, scratch your skin, they get a wheel anyways, then it's a little bit hard to interpret the testing on DSO. We do take those considerations if their skin is pretty involved, that we wouldn't be able to do skin prick testing. Um, also, you do have to hold your anti histamines in general with normal anti histamines. It's about five days that they would have to hold it. So if for some reason they're unable to hold their anti histamines or medicines that would have anti histamine allergic properties, Um, that's another reason that we often would consider doing the blood allergy tests instead, Onda, then interpreting this test is like I said, a little bit challenging at times. So one thing is the size of the wheel or the level of the concentration of specific I G actually doesn't tell us or reflect how severe reaction is. It does tell us how likely it is to cause a problem. So if you have, you know, a three millimeter wheel to maybe mountain cedar and you have a 10 millimeter wheel to dust mite, you're probably a lot more allergic to dust mite than you are to mountain cedar. Um, but to both of those, you might have runny nose congestion, seizing the same sort of reaction. So it doesn't really reflect sort of the severity of the reaction itself and then for different allergens. There are different test characteristics like we were mentioning. So for arrow allergens, skin and blood are fairly equivalent. They actually match about 85 to 95% of the time. So I will often say, whichever the patient really prefers. Is that what I think? Okay to use for testing? Um, foods. It does depend a little bit on history, and we'll talk about this a little more in the food allergy section. But often, if I'm very worried about somebody having a food allergy, I will use potentially both forms to, um to sort of manager and track their food. Allergy for venom and drug. Interestingly, skin testing and even doing adding what's called intradermal, which is just essentially like a TV test. We put a little bit of the drug underneath the skin. Um, is actually the best form of testing for both venoms and drugs on dso the the blood. Sometimes we'll add for venom. But for drug blood, allergy testing is actually not very reliable. It also we usually don't recommend it for those. So that's a good summary for indications for allergy testing again A concerning history, and it's helpful because it can help confirm or exclude I g sensitization sensitization, determine how we would recommend allergy avoidance and guide the selections for allergy immunotherapy. So one of the biggest reasons we do this for allergic rhinitis on DSO just some key pearls for this is some you know, the cardinal symptoms for rhinitis or congestion. Ryan area already knows posterior writing. Your most people call post nasal drip and then sneezing. And there is a differential for us when I think about rhinitis. Obviously, allergic rhinitis is top on that differential, but there's also non allergic rhinitis. And then, if somebody is sort of being treated by those and not improving, that's when I start to think about other problems So anatomically. Do they have chronic sinusitis? Do they have nasal polyps? Do they have other structural abnormalities, like a deviated septum or a mass? Um, that, you know, as people are aging there, Um, a trophic rhinitis is that are associated with surgery on getting a lot of procedures done as well as rhinitis. Medicamentos Uh, so often we will have patients who, after a while, admit that they have been taking a inter nasal decongestant for a long time. And it's a good thing to put on a differential because it can actually be quite significant. I've had to put people on oral steroids to get them off of their African that they were using for honestly for months. Thio even like years of taking daily eso, it could be a really big problem to get patients off of those medicines, so diagnose someone with allergic rhinitis again. This is halftime symptoms Evidence of this specific I g via either skin prick testing or, um specific I g blood testing on Ben symptoms that correlate with that exposure to the allergen versus ah. Lot of patients come to us, and they're like, you know, all my testing came back negative, but I swear I have runny nose congestion. All those same symptoms and those patients are are very, very true, um, in terms of their symptoms. But what we think is happening is they have what's called non allergic rhinitis. So this is estimated enough to 50% of adults with rhinitis and actually can coexist with allergic rhinitis. Um, this is in a race that usually starts in adulthood versus allergic rhinitis, which often people will have since childhood. And some common triggers that you may have heard before are These are the people who say that perfume bleach, household cleaners, um, cold air weather changes, smoke in the air, mold or mildew. Those seem to really irritate the nose. And so we think it's an irritant reaction that they're having that also still causes the inflammation in their nose and still causes the same congestion and runny nose that allergic allergies cause, but through an irritant mechanism rather than an allergy antibody mechanism. So they have completely negative allergy testing, although they can't have quite significant symptoms. Luckily, the treatment is very similar. We recommend that they avoid the triggers that, you know, cause there, um, non allergic rhinitis and then treat them with similar medications. So talking about medications. So there are a number of different nasal steroids. Um, this is what we consider first line. Um, it has been studies been shown to be more effective than Orel anti histamines. And it sort of makes sense. You're placing the medicine right where the problem is. The onset of action is in general very quick. It's within a few hours, but to really have a good effect, it requires that you take it every day for at least two weeks. So for some patients were like, I've tried it. I'm like, How did you try it? Have you tried taking it every single day to see if it really did help? And if they haven't yet, I often ask them to do that trial to see if they really have failed or if you know it was inconsistent application that really said that they weren't, you know, having benefit from it. Um, they sometimes do need a quite a bit of counseling on how to use it appropriately on DSO. In general, I recommend people that they slightly bend forward eso that you know, gravity isn't working against them, point out towards their ear and then spray and then sniff slightly, not enough that it's just all going down the back of the throat, but enough that it's not dripping down anymore. That can help minimize side effects to the medications, um, and help them tolerate it a little bit more. Um, you know, there have been very few studies that have really compared between all the different in traditional steroids in general. There's not a significant difference in efficacy. So most of what I'm gonna tell you next is mostly, um, just in terms of how toe work with patient preference, intolerant cholera, bility of medication more than true efficacy issues. I think in general, if somebody has is on and nasal steroid and it's working, they can continue on that nasal steroid. Um, if they're having issues is sometimes when I start to sort of play with these a little bit. So, um, felonies is probably the most common out there. So since it's so readily available, it's often the first one I will also sort of use and reach for, but it does have a scent to it. It almost smells like flowers. Um, and it does have alcohol in its formulation, so that could be drying and irritating to some people. So some people say that they didn't like the way the phone is worked. Then usually I moved to Neza Court, which is a triumph similar and steroid, and again has no alcohol, no sense. So many patients will tolerate that a little bit better than the Flonase. Um, Ryan. A court often comes up because it's pregnancy category B, which is very nice in general. The nasal steroids are thought to be pretty safe in pregnancy and lactation. But if somebody is looking for for some sort of the safest option of the intranasal steroids, I usually will switch them to write a court, which is also be destiny needs, Um, for patients who have who say that they don't like spring something up their nose, they don't like that sensation. They do have a couple of newer devices that can change how the medication is administered. So flown a sense amiss is floating his own furor. Wait, Um, and it comes in this mist formulation so it does like spray and little tiny droplets essentially, just really nice because it doesn't have as much stripping. There's not as much of that sort of. Some people will notice a bad taste in the back of their mouth. Um, there have been studies as well that maybe show that it has a little bit better deposition within the nasal cavity and then maybe a little bit less episode taxes. So if people are starting to complain of not being able to tolerate it despite, you know, using the right technique, they're having nosebleeds or just feeling like it's not working super well, sometimes I'll have, um, try a phony sense chemist. Um, que nasal or zatanna are two other ones that are similar. They're actually prescription, and the challenge here is honestly getting it covered. Um, it is nice, though, because it's an error stylized form, so that is actually a little bit even easier. Um, in terms of the droplet size than the mist to tolerate Andi. In fact, it's used a little bit differently because you spread and then you actually have to hold your breath, since it's aerosolized but again has the same benefits, Um, in terms of not dripping less bad taste, potentially better deposition and less, um, episode axis, which is really nice for patients in general. What I also tell people is that these medicines are really safe. I'll be completely transparent and say that I have allergic rhinitis and I'm allergic to pretty much every single pollen and dust fight. And then in part is why I'm an allergist. And so I actually take a nasal steroid. I take nasal court every single day on I have for years. So in general, these medications are pretty safe. Um, there were concerns about, you know, things with long term use of steroids like adrenal suppression, growth, bone, mineral density, glaucoma, cataracts and, in general, the long term complications of these air. Pretty small on dim part. That's probably because the doses so small this is micrograms versus milligrams of oral steroids, um, and also because it's locally applied with just a little bit potentially of systemic absorption for patients who are on it for a long time just because the eyes air so close to the nose. I do recommend that they get regular eye exams, just thio sort of watch for glaucoma or cataract formation. But other than that, I really don't commonly see other problems with taking these medicines, even for years on end, which is pretty nice. Okay, there are a couple of other therapies, Um, that I do use as well. Eso the next medicine I usually talk to people about is called a stolen or as a lasting nasal spray. So it's actually a prescription anti histamine spray. And in studies, the topical anti histamine tends to work better than an aural anti histamine for nasal symptoms. So if people are noticing that they have a lot of symptoms, um, despite using the phone ease, this is usually the medicine I start using next. Um, this one does really have a bitter taste to it. About 20 to 30% notice it. I even notice it, but I think it goes away pretty quickly, eh? So I've been able to tolerate it pretty well, but it's 1 to 2 sprays twice a day as needed. What's nice about this is I almost use this like albuterol in some patients. So it works pretty fast because it works by blocking histamine versus steroids, which need to reduce inflammation over time. And so for me, I even do this. I take my phone is every day. But if I'm going over to someone's house with a cat, which I'm allergic to else use my Asselin because I know I'll sort of need extra therapy at that time. So I sort of use this on top of my everyday medicine, um, for benefit. So I think I have been using reaching for this a lot in my patients right now who have been out of control with the smoke or with other, you know, with other worsening of their allergic symptoms in this time frame. If they are already doing their nasal steroid and doing it regularly and correctly, um, the next medicine that I usually like, let's add on to see if it would provides you additional benefit. Is this Assulin spray? Um, the drug companies got smart and they made I missed A, which is a prescribed prescription combined steroid anti histamine spray eso instead of having to use maybe Flonase plus as last team. Now you just have one medicine that you spray. The hard part is this This is not This is also difficult to get covered. It costs about $80 according to good Rx. So usually I just end up prescribing the Assulin in the phony separately. Um, there's also something called Atra Vent or potro Priem. And here, um, similar to the airways. We use it, um, sort of as needed as well. It works specifically Thio crease decrease, uh, mucus gland secretions. So this really works well for people who have, like, a faucet running nose faucet. They said that they're just always their nose is running. This medicine seems to really help. And classically, it helps with something called gustatory rhinitis, which is a form of non allergic rhinitis. Um, in where people, every time they eat their no starts to run. Um, and so the the classic recommendation is to use the petroleum about 30 minutes before they eat, so that you can help with that reflects That's happening. Another medicine that I have been reaching for quite a bit or I guess it's maybe even not. Medicine is saline rinses that can really help people because it does wash mucus as well as allergens and irritants out of the nasal passages, Um, in sort of clear they the upper airway out for then they can apply a topical medicine into this fresh, new new cosa. So for people who do feel very congested or like, they have a lot of sort of stuff in there, I do find that saline rinses can usually help them quite a bit if they use it one time when they're feeling very congested, or even regularly to help sort of maintain their nasal passages. If people have a lot of I symptoms as well, I usually will also recommend an anti histamine I drop pat today or, um, Ola padding is now over the counter. A swell Azad a door, which is Kitada. Fini drops in. Both of those usually worked pretty well. Um, Orel. Anti histamines are obviously a common medicine that are often used again. These seem to be a little bit less effective for nasal congestion than the nasal sprays. But if people are tolerating it well, I think that's totally fine for them to continue using, Um, if people of other symptoms often I will also use it in those situations like someone who gets hives with grass. Obviously, they're nasal spray is not gonna work super. Well, for that, um, all the again in studies, all the different oil and histamines were similarly efficacious. So there isn't super strong evidence. Ah, population level for using one and a history over the other. Also, there's not strong evidence of sort of pharmacologic tolerance. So I will say anecdotally, a lot of people say this one works better for me. Um, this one stopped working after a while, and I switch back and forth. You know, in studies, we haven't specifically seen that. Although I think individual people, maybe that is true. So if people do find what works best for them, I'm totally on board with them using sort of what works best for them. Um, some considerations are that about if you get higher up higher doses on Claritin, if people are taking it two or three times a day, which will we talk about why people do that? But if you do higher doses of Claritin or loratadine Then you can start to see more sedation as well. A satirizing or Zyrtec. About 10% were notice sedation. So if patients are complaining more about sedation issues than I usually will go to Allegra or, uh, Dessler Aladin, which is clear next. Or leave a citizen, which is is all for those with renal disease loratadine Claritin is probably the favored in a history. And then, for those with liver disease, leg or a fexofenadine is probably our favorite one. I showed this last time, so I'll talk about it just briefly but singular in March got a box warning on it for potential of serious neuropsychiatric events. Um, this included anything from mood changes to vivid dreams to memory problems, suicidal thoughts or actions. Um, and it wasn't a new study or anything specific. It was that the FDA, it continue to receive reports of these side effects with Monta Lucas use. And so it does say in here that because of the benefits of singular may not outweigh the potential risk. Reserve the use for patients who have had an inadequate response or intolerance. Alternative therapies. So it definitely is not my first medicine that a pullout for someone who has either allergic rhinitis or asthma. Um, and I definitely council people on the potential for the side effect before I would use it in them. Okay. And then, um, really briefly, we'll talk a little bit about what would be next. So if people have been on Flonase, they've been on Assulin. They're already trying to do their best to avoid all the allergens. Then that somebody that we usually are starting to think about allergens specific immunotherapy for this, what we're doing is we repeatedly administer their allergens, um, to them to try to induce tolerance. I tell people it's basically like a personalized vaccine of all the things you're allergic to that I'm giving back to you to try to make you, instead of having an allergic response to it, have a tolerant response to it. In general, we know that if we are able to put someone on immunotherapy, they tend to have less symptoms, need less medication, and it seems to have build tolerance. Where, after they stopped their allergy immunotherapy for years afterwards, they will continue to have a benefit from it, so it can really help the number of patients. Um, in general, the strongest indications are for allergic rhinitis and for allergic asthma. Um and so I start to think about using this and people who are poorly responding to their medications and their allergy event avoidance who have adverse effects of those medicines. If they just don't want to take medicine long term, that's a reasonable reason to use it. Um, potentially also can prevent the development as my patients with allergic rhinitis, although we tend to think that would probably be in Children. Um, rather than adults. Um, as a process. It is pretty involved, though, so it must be done in person. Do allergy shots must be done in person due to the risk of reaction. And, um, we have to do what's called a buildup phase where we started a 1 to 1000 dilution, um, and then build them up to the one. The one dilution and the maintenance dose of that 1 to 1 dilution. So taking shots. What we do is we started 1 to 1000, give them that dose and then slowly step up every week for about six months. And then once they get to maintenance, we do are able to space it out to every month for about 3 to 5 years to build tolerance. So it's a, you know, 3.5 to 5.5 year process. The patients do really need to have sort of the ability to do that A and also be committed to doing that in order to really use it in a successful manner. There are some new sublingual immunotherapy is which is hopefully trying to reduce some of those things thing unfortunate thing is, right now they're only first single agents. So there's a ragweed tablet. There's a northern pasture grass tablet, or there's two northern pressure grass tablets. And then there's a dust mite tablet. So really there, most useful for people who are sort of mono sensitized to their only dust mite allergic, although occasionally I have used it for people who have multiple allergens but dust mite of their biggest problem because it won't do anything for their other allergens. Um, what is nice about this is the first dose we recommend observing so that we can make sure they're not gonna have a reaction to it, but after that, they go home and take the tablet every day at home by themselves. So I no longer have to be sort of in person on dso sort of taking the time out of their day to do that. Although they do need it obviously take their pill themselves at home. Um, which is really nice. So best practices for managing chronic rhinitis. So first line, I would say, if you know, for your basic patient, if they're already doing okay with what they're doing, I think that's totally reasonable for them to stay. And Orlando Histamine International spray whatever is working. But if someone is having persistent symptoms, usually my first step is to go to a regular use of an international steroid. Um, if they're already on that or if they've tried that in the past, it hasn't worked. I usually then reached for the intranasal anti histamine and potentially talk to them about doing saline rinses. And if the failing this, they probably should come see us to make sure we can find out what they're allergic to so they could do better avoidance and potentially talk about immunotherapy. Okay, so next thing we're going to talk about is different food reactions um, so this is probably a pretty common thing I see in my clinic, and I'm sure you get a lot of questions about. And so the first thing I usually talk to patients about is that there are a number of different types of food reactions, and what we call food allergy, which is due to an allergy antibody, is actually only one type of those different reactions. And so other types of reactions that I usually just give people examples are off our celiac disease and the immune mediated reaction. Um, but not due to analogy. Anybody do toe other antibodies, which also means that people can't eat a week without or gluten without having a reaction as well as other sort of non immune mediated reactions, which in general are terminology for this is food intolerance. Maybe the most famous one is black toast intolerance, where, you know people don't have the enzyme to break down lack tastes. And so every time they drink milk, they have the issues a swell with eating, drinking the milk. And so I used that framework to tell patients that there are many different types of reactions. But the reactions that we worry about for allergies would be the ones that we would think would be related to an allergy antibody. And those are the ones that allergy testing would be useful for, um, versus the other ones. Allergy antibodies aren't involved, so allergy testing isn't as useful for so some classic features of sort of an allergy antibody mediated reaction is they're pretty rapid and onset, so they usually happen within two hours, I give them, but honestly, often it's while they're still eating the food. They also resolved pretty quickly. You know, somebody can actually, in a flaccid peanut, digest that peanut and then go home after monitoring, you know, four hours in, um, in the d the same day. So they people who tend to have rashes that last a long time, or bloating and stuff like that that tends to be less likely or less common to be related to an allergy antibody. Immediate reaction. And then it's also consistent. Sometimes I'll have people come in and say, you know this one. Cheese causes me problems, but yogurt, milk, ice cream, those are all okay. So in that case, they're probably not allergic to milk because the allergen would be in the milk proteins, so they would be allergic to sort of all different forms of it. Also, what helps us is knowing what allergens air probably a lot more common. Over 85% of food allergy, we think, are due to, um, the top eight food allergens. And although about 20 to 25% report Ah, food allergy, um, studies actually show that about 2 to 3.5% of adults true, we have a food allergy. If you actually look at that in sort of oral food, challenge is so the most common allergens are the ones that are listed here milk, egg, wheat, soy fish, shellfish, peanuts and Trina Sesame. I've added in here because it seems to be an up, up and coming allergen that's more common. There is also differences between Children and adults, so milk, egg, wheat, soy are more common in Children, and then you actually tend to outgrow. Which is why then those numbers go down, um, in adults. Peanut Trina, some peanut is outgrown but can definitely last their lifetime. Trina is honestly pretty uncommon tout, grow and then fish and shellfish and just they are more common in adults. So that's the one that if someone comes in and you know as an adult and is referred to me, I'd be a lot more worried that they had a true food allergy if it was, ah, fish or shellfish. Another common reaction that I, uh, I didn't know a lot about before I became an allergist to something called oral allergy or pollen food allergy syndrome. So this is actually because there are a lot of proteins in foods that look like pollens on DSO. When you eat them, you get a contact reaction in your sort of mouth, tongue lip throat area because your body thinks you're trying to eat pollen. So some key features are this are that they only have symptoms in that region. They only get itching, tingling, redness, swelling of the lips, mouth, tongue and throat. They have no other symptoms at all. On Ben, they resolve once they go, their stomach don't have any other problems because once the allergen is broken down by the gastric acid and digestive enzymes, it no longer looks like pollen. And they're like, Oh, it's not actually the birch tree that you're trying to eat and causing the problems. Interestingly, symptoms also only develop in response to raw, uncooked food because once they get cooked and heated that again, the protein is denatured and also doesn't look like the pollen anymore. On dso these air some common allergens that people will tell us. So, for example, apples are really common. When I hear some people will say, Oh, yeah, I always get itching with apples. So I thought I was allergic to apples. Um, and in general, that is somewhat true. You know, we tell them to avoid the form that causes the symptoms. For example, if it's raw apples that cause you symptoms, um, you can avoid that, but feel free to eat them cooked because it wouldn't cause your problems. So applesauce have apply totally fine for most patients who have oral allergy syndrome for most patients. They don't need to carry an epi pen because they will. They are essentially, um, not at increased risk for an AFL axis. But if people want to, I think that's definitely okay. And they're just, you know, counsel them on it. Hopefully, they don't anticipate that they'd ever need to use it on dso food allergy testing. So again, this is where testing does not diagnose someone with allergen. So we only recommend testing foods that have a reaction consistent with an allergy antibody, Um, reaction on bats because about 50% of people can have asymptomatic sensitization. So without a good history, we say that doing a food allergy test is actually no better than flipping a coin. Um, and this is honestly, very personally true, even for me. So I'm allowed to tell pollens and trees and grasses and weeds all of that. But I have no food allergies, but I have been tested to milk, and I have been tested the soy just because people are practicing testing and I test positive. So that means I make a wheel when I am tested to milk and soy. But I drink milk every single day. I have so it all the time, and I have never had a clinical reaction to it, So I have sensitization. I My body has made an allergy antibody, but I am not allergic to the food because I have no reaction at all. So there in lies the problem and why we don't recommend sending indiscriminate panels and tests that don't seem consistent with an allergy antibody because you'll probably have the potential of finding false positive that are not clinically relevant. We also don't recommend sort of non standard tests. For example, food specific I G or G four. Um, those in general tow us. You know I g or something that you make when you have built tolerance to something s o. They may reflect tolerance, if anything, although it hasn't been correlated specifically with the issue disease, a disease state. So we just don't recommend those tests that sometimes we will get, like, food sensitive test online because they essentially are non interpret herbal in terms of people's food reactions. Um, food allergy testing is also ah, little bit challenging because it's also not just positive or negative that we look for. So they're cut offs for different foods based on their reference to different Orel food challenges. So, um, you know, for E would not expect you to memorize these numbers or even know these numbers. But essentially, this is to show you that you know, there are different numbers that which we consider the likelihood that they would have a reaction. And so it's not just a simple number that we sort of look at. And this is when why we are often using both skin testing and blood allergy testing for patients who truly are allergic. Um, and honestly, it's probably pretty challenging to interpret, and so should really probably be seen by an allergist to have food allergy testing interpretation. So this is just a quick slide, Um, that I was going to run through Thio give some examples. So abdominal pain after eating eggplant. I probably would not recommend testing unless they had other symptoms that might be more consistent with an intolerance. Like um, I B s type intolerance, um, hives swelling after eating peanut 100%. That sounds very much like a food allergy rash for two months. Uh, probably less likely, given the length of symptoms, that it's related to a food because they really digested. And that foods kind of out of their system so that it would cause this rash for two months would be pretty unusual in terms of allergy antibody mediated problem, um, eczema. That's a little bit complicated. I will say. There do seem to be some people with eczema who have a consistent worsening of their eczema after eating a food, it seems to be pretty rare. So I usually counsel patients with eczema about this and talk to them about whether they want to do testing or not. If they're currently eating a number of foods and are not noticing that it seems to be particularly related with any specific reactions, it's probably less likely that they have a food allergy. And so I don't like people to be avoiding foods if they don't need thio. And given the risk of false positives, I often like you know, it probably is not worth it. But if someone do, does see a consistent pattern or has concerned, obviously for a true reaction like they additionally, they have eczema. But also I have hives and swelling after eating peanut. Then I definitely do talk to him about testing runny nose with spicy foods. Less likely, maybe they have gustatory rhinitis flushing with alcohol. Less likely, that's probably do more do than alcohol intolerance. Um, chronic voting again, less likely. So food allergy, pearls, eso We talked about that There are different types of adverse food reactions that allergy antibody mediated reactions are the ones that we consider food allergies, and those usually our immediate consistent has classic clinical features. So we don't recommend allergy testing for reactions that don't have classic allergy characteristics. Eso for drug allergy. What I really wanted to highlight here was penicillin allergy on dim part because this is such a huge problem in our world. So about 10% of patients report of penicillin allergy, but we now know that about 95% of those patients will be able to tolerate a penicillin. Um, and this is in part because it's unclear sometimes how how true of the history of penicillin allergy they really had. Sometimes you probe them and they're like, You know, my mom had a reaction, or I was told not to try to penicillin because of X y Z. And so sometimes it's not a true allergy to begin with, but they actually looked at specifically people who were proven to have a penicillin allergy test positive, and then they follow them for five and 10 years and actually showed that 90% of those patients would actually outgrow their penicillin allergy with testing negative over time and then actually doing what's called a challenge where they gave them back of penicillin. And they did not really react any longer s o For many, many patients who have this reported penicillin ology, many of them would be able to take a penicillin again. And we can actually eliminate that penicillin ology off the record, which is great. Skin testing is actually really, really good for penicillin. Allergy on dso. That is really nice. Um, and we know it's a big problem. People who are who have enlisted penicillin allergy on, um, their record. Um, that actually has real consequences. They're more likely to receive broad spectrum antibiotics that could be more toxic, less effective and more costly. Um, they are more likely to stay longer in the hospital. They're more likely to develop Mersa V R E C diff because of those broad spectrum antibiotics that they receive s so it can be very, very helpful and to clear their penicillin allergy for patients and for our society as a whole to obviously decrease in antibiotic resistance. So we would recommend that you refer them to us for evaluation. We actually have a penicillin testing evaluation clinics specifically designed because there are so many patients that we know have penicillin allergy, where we mix up the penicillin on that day and we just go through and test every single person in the clinic for penicillin. Allergy on board. This could be, you know, particularly helpful if they have recurrent infections. Infections where the best therapy would be. A beta lacked him if they have a plan, surgical procedure if they have upcoming chemotherapy or transplantation. I personally always recommended to young woman because I know that they potentially we might get pregnant. They potentially might have GPS. They may potentially need GPS prophylaxis on DSO. That's a clear indication for penicillin. We're also happy to see other patients who have other drug allergies as well, especially if they would need that drug again. So aspirin allergy in a patient with strokes like analogy to patient who needs local anesthetics, chemotherapy reactions, oncology patients. So we would be happy to see any of those patients as well. Um, and then less topic hives. So when I'm thinking about hives, one of the first thing I sort of start to think about is one of its acute episode So in our world we create this, um, cut off of six weeks. Although I will say six weeks is a little bit of an arbitrary cut off but acute Arctic areas when you have it for less than six weeks versus chronic Arctic areas over six weeks, um, and to us or to Carry and Andrew Dema are pretty similar. Um, if people are having it together because Andrew Dema is essentially er to carry just one layer lower in the Durmus for acute order Correa, that's when we start to think of things like, Ah, viral illness is honestly the most common cause because of acute editorial episode, but also allergic reactions to medications which you know generally things we think about our antibiotics also something I usually talk to patients about is they're over the counter use of medicines, for example, and sets are super common cause of hives and swelling. Um, that sometimes people won't, you know, think of initially because they don't think about the ibuprofen that they took for headaches or for, you know, pain. Um, for some other reason, um, environmental allergens are a potential, but usually if they have, um, hives, they also have other symptoms. So I'm allergic to cats. I get hives, but I also get, you know, runny nose congestion, sneezing, itchy eyes, um, even wheezing if I stay long enough. So usually I don't see her to carry in isolation unless the exposure was specific. Like sitting in the grass or something like that. Um foods, Um, And then there's also a number of other things, like noninfectious Congo's physical agents, psychological factors. A swell, um, but if somebody's having chronic or to care where they're having it for, you know, over six weeks, that's pretty unusual for it to be a single allergen, Um, in general. And so here we're usually splitting it up to either chronic spontaneous or decay. Or some people call chronic idiopathic arctic area or invisible Arctic areas so induce about what occurs in general, where a specific thing often will cause it. So that's dramatic. Graph is, um, if they get, you know, scratched cold pressure Sun heat vibration, Colin ergic, which is usually anytime their coal allergic um system gets activated. So anytime there passively heated. So whether they exercise or in a sauna, hot shower or something like that will make it worse. Um, contact aqua genic. It's not in here, but exercises often another one I asked people about. So those are all triggered every single time. You know it's chronic because it's always happening, but it's triggered by these specific physical. Um, triggers usually run through those triggers with patients on Ben Chronic idiopathic or to carry is probably the grouping of everybody else. And so this is something I probably we think it's about happens in about 1% of the population, but I probably see someone with chronic idiopathic or to carry every single day. Um, and so this is people who are having hives pretty much every single day for over six weeks. So obviously it's pretty hard to think of an allergen or exposure that was causing that comment of symptoms to be around Some red flags. Symptoms that I usually go through with patients as well is, um, you know, to these are essentially to rule out Arctic Ural vasculitis, which is pictures on the right. So, um, or you care usually last, um, less than 48 hours. So if they have a high one specific hive, you know the whole process can last for six weeks, but each individual hive usually goes away pretty quickly, so that hi viz lasting for more than two days. That's pretty unusual for a hive. If it's painful rather than periodic on benefit leaves a mark, especially a bruise. That's obviously a concern. So chronic idiopathic Arctic here because this is a common thing. I think I see in that I get referrals for so again, it's hives most days of the week for over six weeks on, but it's usually not due to an allergen. Um, in general, we don't completely understand the pathogenesis of disease, but we think it's likely auto immune. Um, and the way explain it to patients is that they've actually done some studies. And they've taken the serum from patients who have chronic idiopathic Eric area and put it on other people's allergy cells, and it causes them to react. So there is something in their blood that is causing them to react, which makes sense, which is why they have hives every single day, no matter the time of day. No matter what they're exposed to, it's something internal to them that's making them have hives in their allergy cells react, about 40% actually have an allergy antibody against the egg receptor, so the way explain that is, usually you have to have an allergy antibody that brings the allergy into your allergy cell and that causes it to react. But then, in this case, any time your allergy sell sees that auto in a body, it causes it to react. So again that would be in your blood and just always causing you to react. We think the other 60% there's another auto antibody or some other feature that we just haven't identified yet. Not that the other 60% don't have the same process going on. But what's really great is in general, the prognosis for this is really good. Usually this goes away, so that means system gets activated by something, causes this auto mean reaction, but actually completely resolves. Often it's within six months. Um, some. The median is probably around 2 to 5 years, so because this problem completely goes away, our goal is usually just to control their symptoms while they're immune, system comes itself down. So that's why for these patients usually recommending high dose and a histamines, which in general, test means up to four times daily dose ing, so that's often, for example, for Zyrtec to tablet twice a day. Um, additionally, there are a number of other medications we can try. So sometimes we'll also put on the H two antagonists. Ah, look a tree and receptor antagonists. Zoeller's probably Oro Melisa map is probably the next best medicine that will usually try or other immune suppression. So again, just differentiate between acute and chronic. The biggest thing for acute. Those air most commonly caused by an infection. A reaction to medication, food, insects saying something else versus chronic that's must more unlikely. Have an alert, um, allergic cause. And so definitely refer. If someone has a cuter care with a history concerning for an allergic reaction so we can help test figure out what that is, um, for chronic or to carry that's not well controlled by Anna historians. That's also a good reason for them to see us. So these are just all those learning objectives and one slide