Allergy & Immunology
Expert discussions on allergic conditions, immunodeficiencies, drug hypersensitivity, and immunotherapy approaches.
Recent Discussions
In a CSU patient transitioning from Xolair to Rhapsido, how long after the most recent Xolair dose do you start Rhapsido?
Since Rhapsido works as early as two weeks in most patients, I would recommend starting 1-2 weeks after the last Xolair injection to avoid breakthrough hives. This, of course, depends on whether the patient on Xolair is completely controlled or not. If not controlled, I would stop Xolair and start R...
How do you counsel a patient who inquires about the role of a GLP-1 receptor agonist as a treatment for mast cell activation syndrome (MCAS)?
While there is evidence of symptom improvement in a recent case series of MCAS patients on GLP-1 agonists, it is not sufficient by itself AND IT DEPENDS ON WHETHER OTHER APPROACHED HAVE BEEN EXXAUSTED. ONE should pay careful attention to the patient's BMI and weigh the potential benefits against the...
How would you approach diagnosis of a patient with recurrent episodes of abdominal pain, severe myalgias, low grade fevers and urticaria?
Without the mEFV variant, from a rheumatologist viewpoint, the differential includes IBD, a periodic fever syndrome such as FMF or FCAS, and MCAS. Therefore, I would consider that workup with genetic testing (anyone can send!), fecal calprotectin, and MCAS eval with A/I. I don't think of urticarial ...
What clinical features push you to add dupilumab instead of escalating ICS dose in a patient with biomarker-high asthma and recurrent exacerbations?
The Phase 3 QUEST study addressed this question and found that adding dupilumab to medium-dose ICS/LABA provided significantly better control than placebo plus high-dose ICS. However, this study did not look at actual dose escalation of the ICS prior to instituting the biologic. They also found no s...
Are there instances when isolated abdominal pain is enough to prompt you to give epinephrine during a food challenge reaction?
Absolutely. Persistent, isolated abdominal pain may be alleviated by epinephrine.
How have the 2026 CHEST clinical practice guidelines for biologic management in severe asthma affected your management of these patients given the conditional strength of recommendations and very low certainty supporting evidence using the GRADE approach?
I applaud the panel for their objective, comprehensive analysis of these questions. The recommendations that they made for the 7 clinically relevant questions are sensible and actionable. The challenge, even using GRADE-based recommendations, is that (appropriately based upon existing evidence) the ...
What is your approach to a patient with undetectable MMR titers checked prior to or during immunosuppression and a history of MMR vaccination in childhood?
MMR titers are good correlates of protection. If any titer is undetectable it could be one of these situations: Primary failure. The components of the MMR have different efficacy. Two doses of appropriately given MMR will have 96+% against measles, but only 88% for mumps. Thus 1 in 10 appropriately...
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
Do you read contact patch tests on removal at 48 hours, and do those results matter if negative at 72 or 96 hours?
Great question, and one that comes up frequently in clinical practice. I remove patches at 48 hours, and at that point I do perform a quick read or, at a minimum, have the tested areas thoroughly photographed. While it is difficult to draw firm conclusions from a 48-hour read alone, it is genuinely ...
Which biologic do you prefer for severe eosinophilic asthma?
I prefer Fasenra for severe eosinophilic asthma. Its efficacy, safety record, and extended dosing interval are some of the reasons. It also works well if the severe asthma is part of an underlying condition such as EGPA, HES, etc. If the severe asthma is mixed eosinophilic and allergic phenotype, I ...