Allergy & Immunology
Expert discussions on allergic conditions, immunodeficiencies, drug hypersensitivity, and immunotherapy approaches.
Recent Discussions
How do you approach monitoring of specific antibody titers in pediatric patients with 22q11.2 deletion syndrome with normal T cells?
I would start with quantitative immunoglobulin levels (IgG, M, A and E) annually. I'm assuming that the lymphocyte phenotyping has been done and is normal. B cell phenotyping to assess switched memory B cells and transitional B cells could be helpful. It's most important to assess specific antibody ...
In patients with a confirmed allergy to one tree nut, do you recommend continued ingestion of other tree nuts that they tolerate in an effort to increase the likelihood of outgrowing the allergy?
I tailor this approach to the individual patient and their family. I try to balance maintaining tolerance to nuts that are tolerated with prioritizing keeping the patient safe from reactions to the nut(s) to which they are allergic. Often, I will advise families of young children to continue consump...
How do you approach treating patients who develop psoriasis while on Dupixent?
Stop the Dupixent. These patients likely had a non-Th2 driven type of dermatitis e.g. Malassezia yeast hypersensitivity, which is Th17 driven, or stasis dermatitis with autoeczematization, or eczematous drug reaction. Revisit the Diagnostic Checklist for Generalized Dermatitis.
Do you recommend allopurinol desensitization in gout patients who develop a rash on allopurinol therapy?
I don't recommend desensitization for allopurinol-allergic patients. There was a time when this made sense due to the lack of a viable alternative therapy. The process is cumbersome in a private practice setting and not as simple as providing the patient with a prescription for febuxostat.Febuxostat...
Would you consider anti-IL-5 therapy (mepolizumab or benralizumab) to either prevent or treat the more severe manifestations of eosinophilic granulomatosis with polyangiitis, such as "infiltrative" (e.g., cardiomyopathy, pulmonary infiltrates, or gastroenteritis) or "vasculitic" (e.g., neuropathy, palpable purpura, or glomerulonephritis)?
Yes, I would consider early starting biologics for infiltrative EGPA.
How do you approach selection of systemic treatment in a patient with atopic dermatitis with severe itch?
The good news is we have 6 approved options here, 4 biologics and 2 small molecules, and all of these therapies have excellent itch data. Selecting a systemic therapy needs to take other comorbid conditions, medications, delivery preference (pill or injection), lifestyle, and other patient attribute...
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 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 ...
For patients who have received vaccinations post-chemotherapy based on their vaccine titers, is it necessary to repeat those titers over time to make sure the titers haven't waned?
Unless the patient is absolutely free from any infections- even “colds”, sore throats, and sinusitis- I would consider it prudent to check, especially for pneumococcal polysaccharides and RSV. Re-immunize if titers are not protective. They should get annual flu and COVID immunizations.
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 approaches have been exhausted. One should pay careful attention to the patient's BMI and weigh the potential benefits against the...