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A 57-year-old man is referred for evaluation of a skin growth on his back, which was noted during an examination by his family practitioner. The site has never itched or bled. The patient is taking antihypertensive medication and denies a prior history of malignancy including skin cancer. Examination reveals a 1.5 cm erythematous nodule that slightly compresses with application of pressure. Numerous nevi and seborrheic keratoses are noted elsewhere.
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Lyme Disease Awareness Month runs throughout the month of May. It is a month that helps increase awareness and improve efforts on how to reduce the burden of the disease for patients. Approximately 15% of patients with Lyme disease will develop Lyme neuroborreliosis, or neurologic Lyme disease,1 which is an infectious disease that affects the central nervous system (CNS). It can be challenging for patients with neurologic Lyme disease to be diagnosed, especially if they do not present with typical symptoms.
For Maria Arini Lopez, it took her almost 2 years to be accurately diagnosed with neurologic Lyme disease. Looking back, Lopez considers herself one of the more fortunate patients, as she recalls learning that it can take more than 2 years to receive an official Lyme disease diagnosis. Lopez, who lives in central Maryland, shared that her COVID-19 pandemic hobby — gardening — was most likely the culprit of her infection in the spring of 2021.
She did not experience any of the tell-tale signs of Lyme disease, which includes the “erythema migrans” rash – often characterized by its “bull’s eye” appearance. Lopez admits that her unusual symptoms made it challenging for clinicians to diagnose her with Lyme disease. This led to her extraordinarily complicated diagnostic journey.
"
If patients present with inexplicable or atypical symptoms and happen to live in a Lyme-endemic region, testing for Lyme infection may be well worth the effort.
To better understand what it’s like to live with neurologic Lyme disease and how clinicians can improve diagnosis and alleviate disease burden for patients, Lopez recounts her experience from her gradual onset of symptoms to receiving an official diagnosis and how the disease has impacted her daily life.
Take us through your experience of being diagnosed with neurologic Lyme disease. What did your clinicians do well? Did you have any poor experiences?
Lopez: I had dramatically varied experiences with 8 different clinicians, including a primary care physician (PCP), optometrist, dentist, otolaryngologist, urogynecologist, rheumatologist, neurologist, and an integrative medicine physician.
I first saw my PCP in early July 2021 for an annual physical and full workup. I expressed feeling concerned that something was just not right. I was having trouble sleeping and felt depressed. I was also a lot more fatigued than usual.
The PCP dismissed my basic labs (complete blood count, metabolic panel, and urinalysis) as ‘normal,’ and told me that I was ‘doing okay,’ despite my communicating that I was struggling. My PCP confirmed that I had a urinary tract infection (UTI), another urgent care provider gave me antibiotics, and I was sent on my way.
My eyes and mouth became very dry, to such a degree that I began to think it might be Sjogren syndrome or some other autoimmune disease. Several years ago, I had been diagnosed with dry eye and had been faithfully following the dry eye regimen recommended by my optometrist, but it was no longer effective. I had the lowest grade for the dry eye testing thanks to the regimen I was prescribed. Now, I had confirmed grade 3 staining, despite following the same regimen. Based on all my symptoms, she agreed that something systemic was going on and that further testing was now necessary.
When I went to my dentist for my biannual cleaning, I told her about the abnormal sensations, or lack thereof in my lips and tongue, as well as the strange itching in my ears, and she acknowledged my suspicion that I might have Sjogren syndrome. She stated that compared with other patients she knew who had Sjogren syndrome, I had more saliva in my mouth, so she did not think it was the likely culprit, but that it might be worth ruling out. She highly recommended that I see an ear, nose, and throat (ENT) doctor.
The ENT doctor who I saw was extremely thorough. She ordered brain magnetic resonance imaging (MRI) to check for anything that may have been affecting the cranial nerves. Although the MRI was negative, it still ruled out certain outcomes. She also diagnosed me with ear eczema and prescribed a steroid cream and steroid ear drops for both ears. These medications helped immensely with the itching and flaking; however, they did not resolve the underlying discomfort, occasional sharp pain, and lack of flexibility in the cartilage of my right ear.
The ENT recommended I see a rheumatologist to completely rule out Sjogren syndrome and other potential autoimmune conditions, such as multiple sclerosis (MS). The rheumatologist was wonderful! She listened carefully to my medical history and immediately ran a series of more in-depth serological tests for a variety of autoimmune and rheumatic conditions that could possibly explain my symptoms. All of these tests, however, were negative.
What were some notable symptoms you were experiencing throughout your diagnostic journey?
Lopez: Cognitive deficits became apparent, including short-term memory loss, severe brain fog and lack of clarity when thinking, slower processing speeds, and impaired executive function. What used to take me 30 minutes to complete now took hours. I no longer worked as a physical therapist, and symptoms were severely impacting my daily function and work as a freelance medical writer.
Other notable symptoms included daily headaches, neck stiffness, intermittent dizziness and vertigo, severe fatigue and flu-like symptoms, mood disturbances, and whole-body flushing similar to hot flashes that would last up to 30 minutes or longer. My right knee joint began to feel swollen and arthritic. As a manual physical therapist, I had worked for a decade in outpatient orthopedic settings with individuals with knee osteoarthritis and rheumatoid arthritis, so I knew what an arthritic knee felt like to the touch.
I finally turned to a neurologist. After listening to the timeline of my symptoms, he thought of 2 potential explanations. I either had a vitamin B12 deficiency that was contributing to what he called “subacute combined degeneration of the spinal cord,” or there was something of a systemic and infectious nature, possibly viral, that was impacting my neurologic function. He prescribed sublingual B12 along with folic acid and B2 supplementation for 3 months to see if my neurologic symptoms improved. If not, he would investigate possibility that it was an infectious disease.
What happened at the 3-month mark?
Lopez: After 3 months, the supplements had not improved my symptoms, and my health continued to deteriorate. I was preparing to undergo a lip biopsy in January 2022 to see if Sjogren syndrome was the answer. The ENT doctor mentioned that sometimes blood tests did not always effectively rule out Sjogren syndrome, but that a biopsy would be a definitive next step in the diagnostic process.
I read a story about a patient’s experience with an integrative medicine doctor in Northern Virginia. I knew in my gut that I needed to schedule an evaluation with this doctor, or someone else at his practice. On the day I was scheduled for my lip biopsy, I cancelled my appointment and scheduled a virtual telemedicine visit with the integrative medicine specialist. By this time, I was fatigued to the point that traveling any distance took maximal effort.
After listening to my lengthy story, which I had now told upwards of 8 times, the integrative medicine doctor wrote a referral for me to undergo 52 blood tests, including a genetic test called GENIE, as well as the line blot serum tests for Lyme disease. On February 9, 2022, I finally found out that I had an active Lyme infection with Borrelia burgdorferi.
According to LabCorp, diagnosis of Lyme disease using Western blot testing requires positivity of 1 of the following 2 patterns:
- An immunoglobulin (Ig) G-positive pattern, in which 5 of the following Borrelia-specific bands (18, 23, 28, 30, 39, 41, 45, 58, 66, and 93) are positive
- An IgM-positive pattern, in which 2 of the 3 Borrelia-specific bands (23, 39, 41) are positive
My results indicated an IgM-positive pattern, reading:
- B burgdorferi 41kD Ab.IgG
- B burgdorferi 39kD Ab.IgM
- B burgdorferi 23kD Ab.IgM
Although it may have provided more detailed information to definitively confirm a Lyme neuroborreliosis diagnosis, I never underwent cerebrospinal fluid (CSF) analysis, which experts recommend in addition to serological testing.1,2
What did your clinician do well during your original diagnosis?
Lopez: The integrative medicine specialist immediately started me on oral doxycycline. He provided me with extensive background information on the Herxheimer response, preparing me for the possibility that I may feel worse before I felt better. He also prescribed a substantial number of oral supplements to help my body better cope with the die-off and detoxification process. I received an email with a detailed explanation as to each supplement’s purpose and how I was to take them.
After 4 months of treatment with antibiotics and supplements, the Lyme bloodwork was now negative, with only one band (Borrelia burgdorferi 41kD Ab.IgG) showing up as positive.
Fast forward to April 2024, although I completed a successful antibiotic, my sensory paresthesia throughout my body began to worsen again. I underwent additional neurologic testing, including nerve conduction velocity and electromyography testing for upper and lower extremities, a brain MRI without contrast, and complete spinal MRIs with and without contrast.
According to my neurologist, although my large nerve fiber axons seemed mostly intact, Lyme infection has the potential to trigger onset of small fiber neuropathy, contributing to my chronic, widespread skin sensory disturbances as well as several autonomic signs and symptoms, including:
- inability to sweat normally,
- dizziness/vertigo with positional changes,
- extreme fatigue,
- Raynaud-like symptoms in feet,
- loss of appetite and nausea,
- heart palpitations,
- dry mouth, and
- worsening of dry eyes.
These symptoms can flare up again during an acute viral or bacterial infection. A skin biopsy will be necessary to confirm the diagnosis of small fiber neuropathy. Regardless of the final diagnosis, I learned that Lyme disease can affect not only the CNS, but the peripheral nervous system too.
What do you want clinicians to take away from your experience with neurologic Lyme disease?
Lopez: Active listening to the whole story in its entirety is critical and medical gaslighting happens, even to other health care providers, and it is unacceptable. Our symptoms and stories are valid, and they should not only be believed, but taken seriously to avoid potentially permanent neurologic deficits.
It is understandable that health care providers can be limited by their scope of practice or area of specialization, but they should never be limited in terms of referring their patients to a specialist or provider who they think might be able to find answers and provide solutions. These recommendations often lead the patient in the right direction and at the very least do not leave them hanging without answers or effective treatment. Continuity of care matters.
Also, not every patient will present with a history of a tick bite or an erythema migrans rash. These patients may experience progression of concerning symptoms that can mimic other conditions, complicating accurate diagnosis and enabling an acute, early-stage Lyme infection to transition into a chronic, late-stage infection that pervades multiple body systems, including the central nervous system, joints (especially the knees), and heart.
If patients present with inexplicable or atypical symptoms and happen to live in a Lyme-endemic region, testing for Lyme infection may be well worth the effort.
Thank you to all the health care providers that listen, believe, and actively seek answers without giving up. You give patients like me hope for a better future.
Editor’s Note: This interview was edited for clarity and length.
This is the second article in a 2-part series on Lyme disease. The first article Lyme Neuroborreliosis: Expert Shares Key Insights on Diagnosis, Treatmentis available here.
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Caffeinated energy drinks sold at popular chain restaurants have become the focus of increasing attention recently since wrongful death lawsuits were filed attributing 2 cardiac-related deaths to the consumption of Charged Lemonade from Panera Bread. In September 2022, a 21-year-old woman with long QT syndrome (LQTS) died from cardiac arrhythmia due to LQTS after consuming an unspecified amount of the drink and a 46-year-old man died in October 2023 from cardiac arrest due to hypertensive disease after drinking 3 cups of the beverage.1,2
The lawsuits filed by the families of these individuals allege that the caffeine content of the drinks was not properly advertised and that consumers were not warned about the associated risks.3
Cardiovascular Effects of Energy Drinks
Paul Leis, DO, assistant professor of medicine in the division of cardiology at the Icahn School of Medicine at Mount Sinai in New York, believes that many clinicians are aware that highly caffeinated energy drinks are on the market but may be “unaware of how much caffeine they contain and whether they exceed the recommended daily limit of 400 mg as outlined by the FDA,” he said.4 “Also, some patients may have multiple of these drinks per day, which can be harmful.”
"
Providers other than cardiologists should be educated and informed of the risks associated with these drinks ... as they may also be involved in the care of at-risk individuals.
Various studies have linked the consumption of energy drinks to a wide range of cardiovascular side effects, including increased blood pressure, cardiac arrhythmias, prolonged QT interval, cardiac arrest, coronary disease, heart failure, and aortic dissection.5
According to Helga Van Herle, MD, cardiologist and associate professor of clinical medicine with Keck Medicine of the University of Southern California in Los Angeles, the consumption of drinks with high caffeine content can be especially risky for individuals with pre-existing cardiac conditions. These include rhythm disturbances, those with caffeine sensitivity, and those taking medications with the potential to cause side effects such as heart palpitations or tachycardia. “For example, prescription stimulants or stimulant-like medications for conditions including ADHD, narcolepsy, and other sleep-related issues, commonly have palpitations or tachycardia as a side effect. High levels of caffeine intake have the potential to exacerbate these symptoms.”
Although the caffeine content of beverages can vary substantially depending on a range of factors, the approximate amount of caffeine found in commonly consumed drinks is as follows:
- 80 to 100 mg in an 8-ounce cup of coffee
- 40 to 250 mg in an 8-ounce energy drink
- 30 to 50 mg in an 8-ounce cup of green or black tea
- 30 to 40 mg in a 12-ounce caffeinated soft drink4
The large Charged Lemonade from Panera Bread contains approximately 390 mg of caffeine. In comparison, the large size of the recently launched Sparkd’ Energy drink from Dunkin’ includes an estimated 192 mg of caffeine.6,7
“I think issues arise when someone significantly exceeds the recommended limit, typically as an acute ingestion rather than habitual use,” said Catherine Benziger, MD, MPH, director of research at Essentia Health Heart and Vascular Center in Duluth, Minnesota, and member of the American College of Cardiology’s Prevention of Cardiovascular Disease Council. “Drinking 2 or more high-energy caffeinated drinks can put the consumer well over the daily recommended caffeine limit and at risk for heart-related events.”
Dr Van Herle noted that, along with caffeine, energy drinks often contain other substances intended to increase energy, such as guarana, ginseng, and ephedra, which may have proarrhythmic effects.8
Clinical Recommendations
In general, Dr Benziger recommended that patients not exceed the recommended limit of under 400 mg of caffeine per day. This equals “approximately 4 cups of coffee, and the caffeinated drinks at Panera and Dunkin’ would also fall within this range but only if you drink just one,” she said. She pointed out that other products also contain various amounts of caffeine, such as ice cream, chocolate, foods containing coffee, and caffeine pills. While many of these products can typically be safely consumed within reasonable limits, using them “in combination can greatly exceed the recommended daily limit and put people at risk for a variety of heart issues such as increased heart rate, blood pressure, and abnormal heart rhythms, such as supraventricular tachycardia.”
Dr Leis recommends that patients with known cardiac disease, especially arrhythmias, avoid consuming energy drinks to reduce the risk of associated complications. “In particular, for arrhythmias such as atrial fibrillation, the high caffeine content from these drinks could potentially put patients who have rate-controlled atrial fibrillation into an uncontrolled ventricular rate and lead to potential complications,” he explained.8
Additionally, patients with hypertension who consume high amounts of caffeine can experience increased blood pressure due to adrenergic stimulation, he said. “For those who have had a myocardial infarction or have established coronary artery disease, increased heart rate and blood pressure resulting from these energy drinks could potentially cause symptomatic angina from the increased demand on the heart.”
In addition, Dr Benziger noted that people may use caffeine to compensate for inadequate sleep, and depending on the individual, may benefit from improved sleep habits including earlier bedtimes and less screen time in the evening toreduce their reliance on caffeine. For other patients, undiagnosed sleep apnea may be causing excessive tiredness.
“We know poor sleep is associated with cardiovascular disease and heart attacks. The American Heart Association Life's Essential 8 recommends 7 to 9 hours of sleep per night for adults,” she said.9 “If people are using caffeine because they are often tired and not getting good-quality sleep, I recommend they talk to a doctor about it.”
Public Health Measures Needed
Along with steps consumers can take to reduce caffeine intake, several safety measures are needed on the public health level. “We need to have full transparency on the caffeine content of energy drinks so people will know how much caffeine they are getting and whether they are over the recommended level,” Dr Leis stated. Currently, the FDA does not regulate energy drinks or require sellers to list the caffeine content of beverages.10,11
"Another thing I would really like to see is some sort of warning label that perhaps certain populations should avoid these drinks, including but not limited to those with known cardiac conditions and those who are pregnant or breastfeeding—if we start off with at least those 2 groups, I think we would be headed in the right direction,” he suggested.
Dr Van Herle also pointed to the need for labels listing the other energy-boosting ingredients in these drinks to allow patients to make more informed decisions.
Transparency about ingredients and caffeine levels of energy drinks is “particularly important for children, who are often attracted to these drinks because they're popular or their friends are using them or they are for sale at their schools,” Dr Benziger emphasized. She cautioned that young children are especially susceptible to the effects of caffeine and said pediatricians advise that children under 12 years avoid caffeine consumption, that all children and teens avoid energy drinks, and that those ages 12 to 18 years limit caffeine intake to 100 mg per day at most.12
“Providers other than cardiologists should be educated and informed of the risks associated with these drinks as well, as they may also be involved in the care of at-risk individuals,” Dr Van Herle added.
Future Research
Numerous questions warrant attention in future research regarding highly caffeinated beverages. According to Dr Van Herle, “There are several things health providers need to better understand, including how highly caffeinated beverages affect individuals with specific cardiac conditions—especially those at risk for lethal arrhythmias; how these beverages interact with prescription medications that can potentiate an individual’s risk of a heart arrhythmia; and whether individuals in different age groups are more or less at risk of cardiac issues that may stem from consumption of these drinks, especially since much of the marketing is geared towards a younger age group.”13
Dr Leis would like to see research examining the incidence of arrhythmias among individuals with daily consumption of highly caffeinated energy drinks to gauge whether rates are higher in this group compared to individuals with less frequent consumption. Such data could inform recommendations regarding the risk of developing arrhythmias among individuals who frequently consume these beverages.
There is an ongoing need for further research regarding safe levels of caffeine intake and which populations are at risk for acute caffeine toxicity, Dr Benziger stated. She also cited an urgent need for data on the use of energy drinks among adolescents, as nearly one-third of those aged 12 to 17 years reportedly consume these products on a regular basis.14 “This is not my area of expertise as I'm an adult cardiologist, but I think that any behavior that starts in adolescence may track into adulthood and could lead to chronic diseases or poor health habits in the future.”
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A clinical practice guideline on immunotherapy for inhalant allergy identifies quality improvement opportunities for clinicians who administer allergen immunotherapy (AIT). The guideline was published in Otolaryngology–Head and Neck Surgery.
Issued by the American Academy of Otolaryngology-Head and Neck Surgery Foundation, this guideline is intended for clinicians involved in the administration of immunotherapy for allergic patients aged 5 years and older with allergic rhinitis, with or without allergic asthma, who are candidates for immunotherapy or treated with immunotherapy for their inhalant allergies in any care setting.
“The goal is to optimize patient care, promote safe and effective therapy, reduce unjustified variations in care, and reduce the risk of harm,” the guideline development group (GDG) stated. The GDG comprised 17 panel members with expertise in otolaryngology, allergy, or clinical practice guideline development, as well as a consumer/patient representative.
The clinical practice guideline on immunotherapy for inhalant allergy consists of 12 key action statements developed by the GDG. Each key action statement is classified as either an option, recommendation, or strong recommendation.
"
[T]his guideline is intended for clinicians involved in the administration of immunotherapy for allergic patients aged 5 years and older with allergic rhinitis, with or without allergic asthma, who are candidates for immunotherapy or treated with immunotherapy for their inhalant allergies
The GDG developed the guideline action statements based on substantial evidence. Two literature searches were conducted from October through December 2022, with a targeted search in March 2023, for relevant articles published in English. The evidence supporting the guideline includes 23 clinical practice guidelines, 46 systematic reviews/meta-analyses, 62 randomized controlled trials (RCTs), and 81 observational and other studies. Evidence-based statements in the guideline are graded using the Oxford Center for Evidence‐Based Medicine grades of evidence, and recommendation strength was based on an adapted version of the American Academy of Pediatrics classification.
Who Should — and Should Not — Receive AIT?
In its first key action statement, GDG recommended that AIT should be offered to patients with allergic rhinitis, with or without allergic asthma, if the patients' symptoms are inadequately controlled with medical therapy, allergen avoidance, or both, or if the patients have a preference for immunomodulation. The goal of this recommendation is to ensure that patients are offered appropriate immunotherapy and to minimize underuse, said the authors. High‐quality evidence, including 61 RCTs and multiple systematic reviews, support AIT’s effectiveness for achieving symptom control in patients with allergic rhinitis. AIT can also improve quality of life and reduce rescue medication use in this population.
Key action statement 2 addresses who should not receive AIT. Part A of this action statement recommends that AIT not be initiated in patients who are pregnant, have uncontrolled asthma, or are unable to tolerate injectable epinephrine. Notably, available evidence and most recommendations suggest that AIT can be continued safely in women who have already been receiving the treatment before pregnancy and are on maintenance immunotherapy dosing, but the authors advise that women should avoid starting immunotherapy for the first time during pregnancy. Caution is warranted for using epinephrine in patients with hypersensitivity to sympathomimetic drugs and closed‐angle glaucoma, as well as hypertension, angina, and tachycardia.
Part B of the second action statement, which was classified as an option, offered the guidance that clinicians not initiate AIT in patients who use concomitant beta‐blockers, have a history of anaphylaxis, or have systemic immunosuppression. In patients with eosinophilic esophagitis (EoE), clinicians should not offer sublingual immunotherapy [SLIT] but may still offer subcutaneous immunotherapy (SCIT). In HIV‐positive patients, the decision to use AIT should be made after discussion with these patients about the risks and related evidence, the guideline authors said.
Assessing Asthma
Key action statement 3 recommends that patients should be evaluated by an appropriate clinician for signs and symptoms of asthma before initiating AIT, and that before subsequent AIT is administered the patients should be evaluated for signs and symptoms of uncontrolled asthma. According to the GDG, asthma screening and assessment should include subjective data gathered through symptom screening and may also include subjective and/or objective assessments. Before each SCIT injection, clinicians should evaluate patients for worsening and uncontrolled asthma and temporarily withhold SCIT until asthma control is achieved, the authors noted.
SLIT vs SCIT
Key action statement 4 recommends that clinicians educate immunotherapy candidates on the differences between SCIT and SLIT, the latter of which may be offered in aqueous and tablet form. Patients should be educated regarding the relative risks, benefits, convenience, and costs of SCIT vs SLIT. The GDG suggests using a handout or other teaching aid when possible. Both interventions are safe; however, because sublingual routes (aqueous and tablets) are associated with a relatively reduced prevalence of systemic reactions, many providers are able to offer SLIT as a home‐based intervention with daily administration and without direct physician oversight.
Educating Patients on AIT Preventive Benefits
In key action statement 5, the guideline recommends that clinicians educate their patients about the potential benefits of AIT with respect to preventing new allergen sensitizations, decreasing the risk of allergic asthma, and the potential for changing the natural history of allergic rhinitis such that benefits continue after treatment is discontinued.
Compared with other treatments for allergic rhinitis, SCIT and SLIT can induce sustained immunologic changes that may underlie sustained clinical benefits. AIT may also decrease the onset of asthma and reduce asthma symptoms and medication use in patients with allergic rhinitis, with a more robust effect observed in children.
Evidence is mixed on whether AIT is effective in reducing the risk of new allergen sensitizations among patients.
Timing of Treatment
In key action statement 6, the guideline recommends that clinicians who administer SLIT to patients with seasonal allergic rhinitis should offer preseasonal and coseasonal immunotherapy. Multiple RCTs of preseasonal and coseasonal administration have found that SLIT in either aqueous (SLIT-Aq) or tablet (SLIT-T) form are effective. Pollen SLIT‐Aq can improve allergic rhinitis symptoms with birch and ragweed extracts, and 5‐grass pollen SLIT‐T and ragweed SLIT‐T have been effective and safe. Preseasonal and coseasonal regimens may have better economic and compliance benefits compared with continuous regimens owing to their shorter treatment duration.
Selecting Allergens for Immunotherapy
In key action statement 7, the guideline recommends that clinicians who prescribe AIT limit treatment to patients with clinically relevant allergens that are associated with a patient’s history and are confirmed with testing. The selection of allergens for immunotherapy should be guided by both clinical assessment and allergy testing, according to the CDG. The clinical assessment should note the season in which symptoms occur and triggering exposures. Some studies have shown that AIT benefits pertain only to allergens targeted in immunotherapy, but other studies suggest that AIT may generally down-regulate allergic inflammation through nonallergen-specific mechanisms. Notably, effective doses vary for allergens and among SCIT, SLIT‐T, and SLIT‐Aq. Clinicians thus need to include patients in shared decision‐making regarding AIT formulations, the GDG noted.
Treat Limited Allergens in Polysensitized Patients
In key action statement 8, which is classified as an option, the guideline suggests that clinicians may treat polysensitized patients with a limited number of allergens. In the United States, SLIT tablets are available for grass, ragweed, and house dust mites (HDMs). SLIT‐Aq allows for simultaneous treatment with multiple allergens, although SLIT‐Aq is not approved by the US Food and Drug Administration (FDA). Research suggests that single‐agent immunotherapy, such as for HDM or grass, may provide satisfactory control of symptoms for polyallergic patients. Evidence also supports the use of multiple AIT and using 1 or a few allergens by subcutaneous or sublingual routes.
Local Reactions and AIT Escalation
In key action statement 9, the guideline recommends that clinicians who administer AIT should continue escalation or maintenance dosing when patients have local reactions to AIT. Local reactions do not predict systemic reactions, and evidence does not support routine dosage adjustments for local reactions. According to the GDG, patients should be advised that escalating dosage after a local reaction does not increase the risk of either a local or systemic reaction.
Identifying and Managing Anaphylaxis
Key action statement 10 is the guideline’s only strong recommendation. Here, the guideline advises that clinicians who perform allergy skin testing or administer AIT must be able to diagnose and manage patients with anaphylaxis. SCIT is safe for managing patients with allergic rhinitis as well as allergic rhinitis with conjunctivitis and allergic asthma, noted the authors. Systemic and fatal reactions are rare but are a primary concern when administering AIT. “Clinicians administering AIT must remain vigilant, should be familiar with recognizing the signs and symptoms of anaphylaxis, and be prepared to render emergency management,” stated the GDG. “Similarly, patients should also be educated to recognize the signs and symptoms of anaphylaxis as well as being educated on how to administer epinephrine.”
Clinicians are advised to monitor patients for at least 30 minutes after administering SCIT, because most severe reactions occur within that time, noted the authors. Differentiating anaphylaxis from vasovagal syncope can be challenging because these conditions can present with similar symptoms. Vasovagal syncope may be associated with prodromal symptoms of nausea and diaphoresis, and anaphylaxis frequently is associated with urticaria and respiratory distress. An emergency action plan with instructions for using epinephrine should be reviewed with patients on AIT, according to the authors. Antihistamines may be included as adjunctive therapy, but they should not be administered before or in place of epinephrine, the GDG stated.
Retesting During AIT
In key action statement 11, the guideline recommends that clinicians avoid repeat allergy testing to assess the efficacy of ongoing AIT unless there is a change in environmental exposures or a loss of symptom control. Clinical outcomes of AIT are generally evaluated from a patient’s report of a reduction in symptom severity and a decrease in the need for concomitant medication. Skin testing or serum immunoglobulin E antibody testing during treatment is not recommended. “Awareness by clinicians who provide AIT that clinical symptoms and medication use are better markers of effective AIT than repeat allergy testing both reduces unhelpful testing and eliminates the continued administration of AIT inappropriately based on persistently positive allergy tests,” the GDG stated.
AIT Duration
In its final statement, key action statement 12, the guideline recommends that patients with symptomatic control should be treated with AIT for a minimum of 3 years, with ongoing treatment duration based on a patient’s treatment response. Few trials have been specifically designed to evaluate the duration of immunotherapy efficacy, and diagnostic tools are inadequate to identify which patients will have a sustained prolonged clinical remission after discontinuing AIT. “The duration of AIT beyond the recommended minimum duration of 3 years should be determined through a shared decision‐making process after educating on the benefits and risks associated with discontinuing or continuing inhalant AIT,” the authors stated.
Patient Education Materials and Online Resources
In addition to the guideline, the GDG plans to work with its patient advocate to develop educational materials, including a patient handout comparing SCIT and SLIT.
“Implementation of the proposed recommendations contained in the guideline will need additional written and online resources, ideally integrated within electronic medical records and decision support tools,” the GDG stated.
Disclosure: Some of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
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