Subcutaneous Immunotherapy and Pregnancy

Can immunotherapy be started if a patient is pregnant or planning to become pregnant?

No. It is generally not recommended to start immunotherapy if a patient is pregnant or planning to become pregnant.

A systemic reaction occurring during pregnancy may produce severe fetal hypoxia or precipitate premature uterine contractions, therefore immunotherapy should not be initiated during pregnancy.

Pregnancy is not a true contraindication for immunotherapy, but by custom, immunotherapy is not initiated until after delivery.

Can immunotherapy be continued if the patient is on it and becomes pregnant?

Yes, immunotherapy can be continued at the maintenance dose. There should not be a dose escalation during pregnancy.

The immunotherapy dose should not be increased in a pregnant patient until after delivery.

What happens when the immunotherapy extract expires during pregnancy and a new vial has to be used?

When a new vial is used, there is generally a "step down" in the immunotherapy dose. Whether the allergist proceeds to "build up" to the previously used maintenance dose or stays at the lower dose is a matter of debate. Many allergists are more cautious and do not escalate the dose during pregnancy.

Summary

"Pregnancy. Summary Statement 71: Allergen immunotherapy can be continued but is usually not initiated in the pregnant patient." Source: Cox L et al: J Allergy Clin Immunol 2007;120:S25-85. It is customary to hold the dose of immunotherapy until the time of delivery.

Sublingual immunotherapy is safe during pregnancy, also safe when initiated for the first time in pregnancy (study) (Allergy, 2012).

References

Allergen Immunotherapy. AFP, 2004.
Allergy Immunotherapy for Primary Care Physicians. J . Stokes , T . Casale. The American Journal of Medicine , Volume 119 , Issue 10 , Pages 820 - 823 (2006). Link via MDConsult.
Position Statement on the Administration of Immunotherapy Outside of the Prescribing Allergist Facility. ACAAI.
Allergen injection immunotherapy. John M Weiner. MJA 2006; 185 (4): 234.
Use of Immunotherapy in a Primary Care Office. AFP, 1998.
Safe allergen immunotherapy. Postgrad Med, 1996.
Advances in upper airway diseases and allergen immunotherapy in 2007. Saltoun C, Avila PC. J Allergy Clin Immunol. 2008 Aug 9.
Sublingual Immunotherapy. Anthony J. Frew. NEJM, Volume 358:2259-2264, May 22, 2008.
Image source: Wikipedia, GNU Free Documentation License.

Comments from Twitter

Dr John Weiner @AllergyNet: Always wondered about this. Data shows as many SCIT reactions on maintenance as escalation. Many allergists here will stop SCIT

FDA on Transition from CFC Propelled Albuterol Inhalers to HFA Propelled Inhalers

Albuterol inhalers that contain chlorofluorocarbons (CFCs) will not be sold in the U.S. after December 31, 2008.

Albuterol inhalers that contain hydrofluoroalkanes (HFAs) will take the place of CFC inhalers. Both CFC and HFA are pressurized metered dose inhalers (pMDI).

Propellant is one of the most important components of a MDI. The propellant provides the force to generate the aerosol cloud and is also the medium in which the active component must be suspended or dissolved. Propellants in MDIs typically make up more than 99 % of the delivered dose.

FAQ on the transition by FDA

Why are CFC inhalers being phased out?
Due to an international agreement called the Montreal Protocol on Substances that Deplete the Ozone Layer. CFCs decrease the protective ozone layer above the earth.

What HFA inhalers are available?
There are 3 albuterol HFA inhalers:
- ProAir HFA
- Proventil HFA
- Ventolin HFA

FDA has also approved Xopenex HFA with the active ingredient levalbuterol.

How are HFA inhalers different from CFC inhalers?
CFC propellants move the albuterol medicine out of the inhaler so patients can breathe the medicine into their lungs. HFAs are a different type of propellant.

Albuterol HFA and albuterol CFC may taste and feel different. The force of the spray may feel softer from HFA than from CFC.

The spray from a CFC inhaler often hits the back of the mouth. The spray from an HFA inhaler is a fine mist that may actually be easier to breathe into your lungs compared to a CFC.

HFA inhalers have to be cleaned and primed to work properly. Each HFA inhaler has different instructions for cleaning and priming.

A $9-albuterol (Ventolin) HFA inhaler is available from Wal-Mart. It is less expensive than most HFA inhalers but it contains only 90 "puffs" as opposed to 200 "puffs" for all other albuterol inhalers.

References:
FDA Drug Safety Podcasts, Transition from Chlorofluorocarbon (CFC) Propelled Albuterol Inhalers to Hydrofluroalkane (HFA) Propelled Albuterol Inhalers. FDA.
Metered-dose inhaler, from Wikipedia, the free encyclopedia.
Doctors Hear Gripes About HFA Inhalers. Kristina Fiore, Staff Writer, MedPage Today, 03/2009.
Image source: ProAir-HFA Albuterol Sulfate (US), Wikipedia, public domain.

Updated: 03/22/2009

2 new asthma susceptibility genes: ORMDL3 and CHI3L1

Asthma is a disease of unknown etiology with underlying genetic factors. The specific genetic contributions to childhood asthma have been difficult to elucidate. Estimates of the heritability of asthma are as high as 70% (CCJM, 2012).


Human chromosomes (grey) capped by telomeres (white). Image source: Wikipedia, public domain.

Completion of the human genome sequence resulted in the identification of two new asthma susceptibility genes:

- ORMDL3

- CHI3L1

A common genetic variation at a locus controlling the expression of the ORMDL3 increases the susceptibility to asthma and is associated with poor asthma control in children and young adults.

SNPs associated with atopic diseases

Filaggrin gene

Filaggrin is essential for epidermal barrier function. SNP associated with eczema and asthma.

17q12-21 gene

ORMDL3 protein defects associated with asthma.

5q22-32 gene

CD14 is a lipopolysaccharide (LPS) receptor. SNPs associated with asthma and atopy.

3p21-22 gene

CCR5 is a chemokine receptor. SNP can be protective against asthma.

Xp22 gene

TLR7 and TLR8 are recognition receptors for viral ssRNA. SNPs assciated with asthma, rhinitis, atopic dermatitis.

5q31 gene

IL-13 is a cytokine that induces IgE secretion, mucus production, and collagen synthesis (fibrosis). SNPs associated with asthma.

ADRB2 gene

ADRB2 gene encodes β2-adrenergic receptor. Argenteum (Arg) or Arg/Arg phenotype associated with decreased albuterol response compared to Gly/Gly phenotype at residue 16.

ADAM33 gene

Type 1 transmembrane protein involved in cell-to-cell interactions. SNPs associated with asthma.

GLCCI1 gene, rs37972 variant
A variant in the glucocorticoid-induced transcript 1 gene (GLCCI1), rs37972, associated with a decrease in forced expiratory volume in 1 second (FEV1) in response to treatment with inhaled glucocorticoids (NEJM, 09/2011).

IL6R and chromosome 11q13.5 have been identified as risk loci for asthma, and an IL6R antagonist (tocilizumab) may be effective therapy (Lancet, 2011).

References:

Genes in asthma: new genes and new ways. Moffatt, Miriam F. Genetics and epidemiology, Current Opinion in Allergy & Clinical Immunology. 8(5):411-417, October 2008.
A polymorphism controlling ORMDL3 expression is associated with asthma that is poorly controlled by current medications. Tavendale R, Macgregor DF, Mukhopadhyay S, Palmer CN. J Allergy Clin Immunol. 2008 Apr;121(4):860-3.
PTGDR gene in asthma http://bit.ly/og1G7W
Consumer genomics company 23andMe now tests for hay fever, and atopic dermatitis. Clinical relevance is unclear.

Video: How to do nasal irrigation

This ABC video provides a good explanation on how to use nasal irrigation with saline which may be helpful in patients with chronic rhinitis and rhinosunusitis.

The technique of nasal irrigation has been around for centuries and is part of yoga practices but has not been commercialized until recently.

One of the popular products is the Sinus Rinse™ Kit which consists of a squeeze-bottle and dissolvable packages. The manufacturing company NeilMed Pharmaceuticals, Inc. is a physician-founded and family-owned business founded by Ketan C. Mehta, MD, president, and his wife Nina Mehta, chief executive officer. Dr. Mehta is a practicing pulmonoligist in Santa Rosa, Calif.

Dr. Mehta brings his video distribution costs to zero by using YouTube to host his instructional videos:


SinusRinse video

More on the ancient origins of nasal irrigation from Wikipedia:

Nasal irrigation is an ancient Ayurvedic technique known as jala neti, which literally means nasal cleansing with water in Sanskrit, where the practitioner uses a neti pot to perform the irrigation.

Jala neti, though relatively less known in Western culture, is a common practice in parts of India and other areas in South Asia, performed as routinely as brushing one's teeth using a toothbrush. It is performed daily, usually as the first thing in the morning with other cleansing practices. It may also be performed at the end of the day if one works or lives in a dusty or polluted environment.

Does nasal rinsing help against allergies? Yes, if your patient is willing to use it. Many patients dislike the method. http://bit.ly/34PyYD

Rhinosinusitis: Saline sinus rinse recipe by AAAAI http://bit.ly/tnrxX - PDF: http://bit.ly/ol5BL

References:
ABC Video: How to do nasal irrigation. ABC.
Video: Nasal irrigation (nasal lavage). Mayo Clinic.

Related reading
Dr. Ketan Mehta, M.D., on Saline Nasal Rinses. achoo! Blog.
Nasal irrigation from Wikipedia, the free encyclopedia.
Got a Runny Nose? Flush It Out! NPR.
Short, Stout, Has a Handle on Colds. NYT, 2008.
Do neti pots promote sinus health? Washington Post, 2009.
Nasal Irrigation as part of daily hygiene routine? "They brush their teeth, they wash their face, they rinse their nose" http://goo.gl/F0N11
SinuSurf (nasal saline rinse with surfactant) associated with loss of smell "for months to years". Discontinue use (PDF) http://goo.gl/awQUP
Neti Pot, Nasal Irrigation - Pros and Cons and Slideshow. WebMD, 2011.
Is Rinsing Your Sinuses Safe? FDA replies: http://goo.gl/XL5bJ

This Week's Grand Rounds

Check out Grand Rounds (GR), the weekly summary of the best posts in the medical blogosphere.

With more than 200 editions, Grand Rounds has become the contemporary weekly portrait of medicine through the eyes of the medical bloggers.

Pre-Rounds is an article series about the hosts of Grand Rounds on Medscape.com. The founder of GR is Nick Genes of Blogborygmi and he maintains the archive.

Breastfeeding may not protect against allergy and asthma

Recent studies do not confirm the 'conventional wisdom' that breastfeeding is protective against allergy and asthma.

Early reduction in childhood wheezing may reflect protection from viral infections.

Reference:

Breastfeeding and allergies: time for a change in paradigm? Duncan, Joanne M; Sears, Malcolm R. Genetics and epidemiology, Current Opinion in Allergy & Clinical Immunology. 8(5):398-405, October 2008.

Shorter duration and nonexclusivity of breastfeeding are associated with increased risk of asthma symptoms in children. ERJ January 1, 2012 vol. 39 no. 1 81-89.

Differences between commercial IVIG preparations: Gammagard and Octagam

Gammagard Liquid is the first 10% IVIG solution with no added carbohydrates or sodium. Baxter is replacing Gammagard S/D with Gammagard Liquid.

Sodium concentration

Gammagard: No added sodium. When reconstituted with the total volume of diluent (Sterile Water for Injection, USP) supplied to 5%, Gammagard contains a physiological concentration of sodium chloride (approximately 8.5 mg/mL) and has a pH of 6.8 ± 0.4.

Octagam: sodium content of the final solution is ≤ 30 mmol/l and the pH is between 5.1 and 6.0.

Osmolality

Gammagard osmolality is 240-300 mOsmol/kg, similar to physiological osmolality (285 to 295 mOsmol/kg).

Octagam osmolality is 310 - 380 mosmol/kg.

Cost

Gammagard Liquid, Baxter, $129.60/gm

Octagam, Octapharma, $118.34/gm

Prices represent cost per unit specified and are representative of "Average Wholesale Price" (AWP).

Since 1990s, no transmission of infectious diseases have been reported from U.S.-licensed IVIG products.

References:
Intravenous immune globulin. Hopkins HIV Guide.
Octagam, Octapharma.
Gammagard Liquid, Baxter.
Image source: Wikipedia.

Seafood Allergy and Radiocontrast Media: A Myth Supported by Physicians?

Sixty-nine percent of faculty radiologist and interventional cardiologists at 6 Midwest academic medical centers responded that they inquire about a history of seafood allergy before radiocontrast media administration.

37.2% replied that they would withhold radiocontrast media or recommend premedication on the basis of a history of seafood allergy.

The rate of adverse events from radiocontrast media administration at 5-12% for high-osmolality contrast media and 1-4% for low-osmolality contrast media.

Immediate-type adverse reactions to radiocontrast media are virtually always non-IgE mediated and have thus been previously termed “anaphylactoid reactions.” It was recently recommended that the term “nonimmunologic anaphylaxis” be used instead.

Patients with allergy to seafood and shellfish have specific IgE against proteins within the meat of the fish, and that iodine content plays no etiologic role. Radiocontrast media reactions are almost always non-IgE mediated and the the idea of cross-reactivity between iodine and radiocontrast media has been discounted.


Mind map diagram of adverse reactions to drugs.

See a related clinical case: Anaphylactoid Reaction to Intravenous Contrast from AllergyCases.org.



Dr Lockey: Radiocontrast Reactions: Rectifying Misconceptions About Shellfish Allergy and Iodine http://buff.ly/1iZE6WF

References:

Seafood Allergy and Radiocontrast Media: Are Physicians Propagating a Myth? Andrew D. Beaty, MD, Philip L. Lieberman, MD, Raymond G. Slavin, MD. American Journal of Medicine,Volume 121, Issue 2, Pages 158.e1-158.e4 (February 2008).
'Iodine allergy' label is misleading - Australian Prescriber http://goo.gl/C4zQ
AAAAI explains why there is no IgE antibody-mediated "iodine allergy." IgE mediated seafood allergy has never been attributed to iodine, but rather to specific proteins in fish and shellfish http://is.gd/1oRpX

50% of hypersensitivity reactions to contrast media may be caused by an immunological mechanism. Allergy, 2009.
3% of patients who are exposed to iodinated contrast media develop delayed hypersensitivity reactions. Skin prick test is negative but the patch test is positive. Medscape and JACI, 2011.
Image source: Wikipedia, GNU Free Documentation License and public domain.

Algorithm for Hypersensitivity Reactions After Vaccines

Overdiagnosis of vaccine allergy is a major public health problem http://buff.ly/1tI9y44

"True" allergic, or immediate hypersensitivity, reactions to vaccines range from 1 per 50,000 doses for diphtheria-tetanus-pertussis (DTP) to 1 per 500,000 to 1,000,000 doses for most other vaccines.

In the US, the incidence of immediate hypersensitivity reactions to vaccines is 1-2 per 1 million vaccinations. A a true vaccine reaction occurs within the first 2 hours after the shot in 99 percent of the cases.

Some vaccines which include gelatin (e.g., Japanese encephalitis) have a higher rates of serious allergic reactions.

This summary from the journal Pediatrics includes a detailed algorithm for evaluation and treatment of patients with suspected vaccine hypersensitivity and 3 practice cases

References:
An Algorithm for Treatment of Patients With Hypersensitivity Reactions After Vaccines. Robert A. Wood, MD, Melvin Berger, MD, PhD, Stephen C. Dreskin, MD, PhD, Rosanna Setse, MD, MPH, Renata J.M. Engler, MD, Cornelia L. Dekker, MD, Neal A. Halsey, MD, Pediatrics, Vol. 122 No. 3 September 2008, pp. e771-e777.
Image source: OpenClipArt.org, public domain.

Allergy to Wine? Correct Diagnosis May be Wine-Induced Anaphylaxis and Sensitization to Hymenoptera Venom

From ABC:

"If you ask people if they have an allergic reaction to wine, 8 percent of the population will say 'yes, alcohol will cause me to have an allergic reaction."

Differential Diagnosis

Alcohol Flush Reaction

"A metabolic phenomenon called "alcohol flush reaction" is common among people of East Asian decent, and is commonly called an allergy.:

Alcohol flush reaction is a condition in which the body cannot break down ingested alcohol completely, due to a missense polymorphism that encodes the enzyme, acetaldehyde dehydrogenase, normally responsible for breaking down acetaldehyde, a product of the metabolism of alcohol. Flushing is associated with the erythema (reddening caused by dilation of capillaries) of the face, neck, shoulder, and in some cases, the entire body after consumption of alcohol.

Sulfites

"There are a handful of people reported in the medical literature who were allergic to something in the grape. But a lot more goes into a bottle of wine than grapes. Take sulfites, which are commonly blamed for allergies. Vineyards add sulfites to wine to keep it from spoiling into vinegar too quickly. Despite their notoriety, allergists say the chances of someone responding to sulfites are one in 100. Even when sulfites cause problems, doctors are debating whether it is technically an allergy. Especially among asthmatics, sulfites act as irritants to the nose and lungs in a similar way as cigarette smoke and perfume can. You're not really allergic to the cologne if you start sneezing. Whether sulfite sensitivity is technically an allergy or not, the statistic that just 1 percent of people actually react to sulfites."

Oral Allergy Syndrome

An alternative explanation may be "oral allergy syndrome": a cross reaction between pollen in the air and a chemical in food can magnify any existing allergies. Among the culprits are banana, kiwi, melon and grapes."

Wine-Induced Anaphylaxis and Sensitization to Hymenoptera Venom

Wine contains chemical and biological contaminants. Symptoms such as facial flushing, asthma and oral allergic swelling and burning (oral allergy syndrome) have been attributed to these contaminants and food additives.

Recent studies have shown a reported high prevalence of hypersensitivity symptoms after intake of alcoholic drinks with red wine as the most common implicated beverage.

Wine contains many contaminants. Some of them come from Hymenoptera insects that fall into the wine when grapes are collected and pressed. We have found patients with allergic symptoms related to wine consumption who are sensitized to Hymenoptera venom without previous stings.

A Spanish study reported patients with allergic symptoms related to wine consumption who are sensitized to Hymenoptera venoms. Challenges were negative with sulfites, other additives and aging wines, but positive with young wines. Sera from all the patients detected Hymenoptera venom antigens.

The author claims that those were the first cases of sensitization to venom antigens by the oral route.

References:
This Wine Is Making Me Feel... Sneezy? ABC.
Adverse reactions to wine: think outside the bottle. Armentia A. Curr Opin Allergy Clin Immunol. 2008 Jun;8(3):266-9.
Prevalence of self-reported hypersensitivity symptoms following intake of alcoholic drinks. Linneberg A, Berg ND, Gonzalez-Quintela A, Vidal C, Elberling J. Clin Exp Allergy. 2008 Jan;38(1):145-51. Epub 2007 Oct 10.
Wine-induced anaphylaxis and sensitization to hymenoptera venom. Armentia A, Pineda F, Fernández S. N Engl J Med. 2007 Aug 16;357(7):719-20.
Alcohol-induced anaphylaxis to grapes. Alcoceba Borràs E, Botey Faraudo E, Gaig Jané P, Bartolomé Zavala B. Allergol Immunopathol (Madr). 2007 Jul-Aug;35(4):159-61.
Urticarial reaction caused by ethanol. Nakagawa Y, Sumikawa Y, Nakamura T, Itami S, Katayama I, Aoki T. Allergol Int. 2006 Dec;55(4):411-4.

Alcohol Allergy - Medscape blog post, 2011.

Challenge test to metabisulfites - AAAAI Ask the Expert, 2011.
Biogenic amines (histamine) can cause adverse health effects in susceptible individuals http://goo.gl/B2bhA
Sensitization to Hymenoptera venoms antigens by the oral route via wine consumption http://goo.gl/9nXnW
Allergy to wine and beer - consider testing for barley, malt, hops, wheat, corn, rye, rice, oat flour, grape, Botrytis (mold) and Saccharomyces cerevisiae (yeast). AAAAI Ask the Expert, 2011.
Alcohol allergy? 1. Prick-prick tests with suspected drinks. 2. If negative, oral challenge test with increasing doses of the drinks should be performed. http://buff.ly/16uHYbi

Images source: Wikipedia, Free Documentation License.

Largest study of pediatric anaphylaxis shows food is the most common trigger and treatment is often delayed

This is largest study of childhood anaphylaxis reported as of 2008. It included 117 children presenting with anaphylaxis (123 episodes) over a 5-year period to the Emergency Department at a hospital in Melbourne, Australia. The design was a retrospective chart review at a single center.

There was one death. The median age of presentation was 2.4 years. Home was the most common setting (48%) and food (85%) the most common trigger.

Peanut (18%) and cashew nut (13%) were the most common cause of anaphylaxis.

The median time from exposure to anaphylaxis for all identifiable agents was 10 minutes. The median time from onset to therapy was 40 minutes.

Respiratory features were the principal presenting symptoms (97%).

The authors concluded that most children presenting to the ED with anaphylaxis were first-time anaphylactic reactions ( 83%) and the time to administration of therapy was often delayed (40 minutes).

Most reactions occurred in the home with peanut and cashew being the most common causes of anaphylaxis.


Mind map of food allergy.


Eight top allergens account for 90 percent of all food allergies.


Mind map diagram of anaphylaxis.

A recent study in the Annals of Allergy, Asthma and Immunology reported on development reported on development of the acronym SAFE, a mnemonic to remind physicians of the 4 action steps for anaphylaxis treatment:

Seek support
Allergen identification and avoidance
Follow-up for specialty care
Epinephrine for emergencies

Drugs used for management of anaphylaxis are remembered by the mnemonic EASI:

Epinephrine IM
Antihistamines PO, IM
Steroids PO, IM, IV
Inhaled b2-agonists, if wheezing. IV fluids if hypotension.

References:
Paediatric anaphylaxis: a 5 year retrospective review. de Silva IL, Mehr SS, Tey D, Tang ML. Allergy. 2008 Aug;63(8):1071-6.
Anaphylaxis: A Short Review
Food Allergy: A Short Review

@AllergyNet: Coroner's Report of anaphylactic death due to food allergy in Australia http://bit.ly/k2QK0c - A lot to be learned from this tragic episode.

Physical or sexual abuse doubles asthma risk

The risk of developing asthma is doubled among children who have suffered physical or sexual abuse according to a study published in the September 2008 edition of the American Journal of Respiratory and Critical Care Medicine.

Puerto Ricans have the highest prevalence of asthma of all ethnic groups in the United States. One potential contributor to the high burden of asthma in Puerto Rican children is exposure to stress and violence.

Information was collected in a household survey of 1,213 children. The prevalence of physician-diagnosed asthma was 39.6%.

Stressful life events and exposure to neighborhood violence were not associated with asthma but a history of physical or sexual abuse was associated with approximately twice the odds of asthma.

According to the authors, this is the first study to find a link between child abuse and asthma.

The findings highlight the importance of screening for asthma among victims of childhood abuse, and to be aware of the possibility of physical or sexual abuse among children with asthma.

References:
Asthma rates high among abused children. Reuters.
Violence, Abuse, and Asthma in Puerto Rican Children. Robyn T. Cohen, Glorisa J. Canino, Hector R. Bird and Juan C. Celedón. American Journal of Respiratory and Critical Care Medicine Vol 178. pp. 453-459, (2008).

Video: Immunotherapy for Peanut Allergy

AAAAI: Gradual Exposure Reduces Kids' Peanut Allergy. MedPage Today, 03/2008.

Related:

Peanut oral immunotherapy (20 peanuts) induces desensitization, however questions about long-term tolerance remain. JACI, 2011.

Omaha businessman dies after multiple bee stings

Bee Stings Kill Omaha Businessman

Steve Parsow managed Parsow's Fashion for Men, an upscale clothing company at Regency Court that his father founded 50 years ago.

He was mowing the lawn when a swarm of bees attacked his leg. He was stung 12-15 times, sending him into anaphylactic shock, and killing him at the age of 48.

Immediately after being stung, Mr. Parsow seemed fine, then his hand began to swell. The family called 911 and gave him Benadryl, but by the time the paramedics arrived, he "slipped into unconsciousness and lost his pulse."

His wife, Debra, said he had no known allergy to bee stings, but a local doctor says it's unlikely someone would die from that number of stings without an allergy or some other underlying condition.

"Just shut him down, "says his brother David. He says he watched as doctors used shock paddles and tried to revive his younger brother in the ER. "It's already been how many minutes? They told us from the start there wasn't a beat. They could not get a beat."

The 48 year old Mr. Parsow was healthy and was running 6 miles a day every day at 4 AM.

There are over 50 reported deaths per year due to insect stings in the U.S. The most common stinging insects are bees and wasps. They can cause severe allergic reactions including anaphylaxis and anaphylactic shock.


A yellow jacket wasp with a typical narrow waist (left) and a honey bee with a fat hairy "fuzzy" body (right). Image source: Wikipedia 1, 2, GNU Free Documentation License.

IgE antibodies to Hymenoptera venom are present in 20-30% of adults who had an insect sting in the previous 2-3 years.

Systemic allergic reactions occur in 1% of children and 3% of adults. Children generally have a more benign course after insect stings because they usually have only cutaneous systemic reactions. Remember:

C
Children
Cutaneous only

A
Adults
Airway
Anaphylaxis

The onset of generalized reactions is usually within 10 minutes of a sting.

Acute management of anaphylaxis

Drugs: EASI

Epinephrine IM
Antihistamines PO, IM
Steroids PO, IM, IV
Inhaled b2-agonists, if wheezing


Mind map of insect venom allergy. See more mind maps from AllergyCases.org.


Mind map diagram of anaphylaxis.


Bee Sting Allergies Explained by Robert M. Overholt, M.D.

References:
Venom Allergy: A Short Review.
Anaphylactic Shock Due to Bee Sting
Large Skin Reaction to Insect Bites and Stings: Is it Dangerous and What to Do?
A Rare Bee Attack Kills Well Known Clothing Store Owner. Action3 News.
Bee stings fatal for Omaha businessman. Omaha World-Herald.

Related:
CNN: Skateboarder's death underscores insect allergy risks. 5 percent of Americans are at risk for a severe, potentially life-threatening allergic reaction from insect stings http://bit.ly/3PEVtK

Updated: 08/15/2009

ACAAI has an online “HOME” allergen control program

62 percent of patients seen by allergists suffer from symptoms caused by indoor allergens.

Consequently, the ACAAI launched HOME:

Home
Allergy
Management for
Everyone.

The interactive HOME program features room-by-room tips on reducing exposure to indoor allergens.

Related reading:

How can I build an allergen-free home? AAAAI Ask the Expert has some tips: http://goo.gl/dMT91

Image source: ACAAI.

Video: Intranasal carbon dioxide to treat allergic rhinitis

Video: Intranasal carbon dioxide to treat allergic rhinitis

Dr. Casale, Chief of Allergy and Immunology, Creighton University School of Medicine: "It is a little bit of a strange idea when you think about it. It's in a higher concentration than you would normally exhale. And it's in a more rapid flow."

The preliminary results from CO2 treatment in allergic rhinitis were promising and had fewer side effects than current therapy.


Medications for Allergic Rhinitis.


Allergic rhinitis mind map. See more Allergy and Immunology mind maps from AllergyCases.org.

References:
Carbon dioxide may treat your allergies. ABC.
Allergic Rhinitis: A Short Review
Mind Maps: Allergic Rhinitis

Peanut allergy transferred between a donor and recipient of a lung transplant

The 12 year old lung donor died from anaphylactic shock after eating peanut-containing food.

Seven months after the transplantation, the 42 year old recipient (no prior history of peanut allergy), had an anaphylactic reaction after eating a peanut butter cookie. She survived.

Skin-prick testing confirmed peanut sensitization. Although her skin-prick test eventually became negative, she still manifested peanut allergy when challenged orally with the food.

Lung tissue contains 600,000 mast cells per gram with each cell having 135,000 IgE receptors.

Transfer of peanut allergy from donor to recipient has been described after liver transplantation.


Eight top allergens account for 90 percent of all food allergies. See more Allergy and Immunology mind maps here.

References:
Peanut allergy may be transferred by lung transplantation, case shows. Roger Dobson. BMJ 2008;337:a1512.
Transfer of Peanut Allergy From the Donor to a Lung Transplant Recipient. Imran Khalid, MD, Edward Zoratti, MD, Lisa Stagner, DO, Alan D. Betensley, MD, Hasan Nemeh, MD, Lisa Allenspach, MD. Journal of Heart and Lung Transplantation doi:10.1016/j.healun.2008.07.015.

Fruit juice and fexofenadine (Allegra) should not be mixed

According to ConsumerReports: "A few years back, doctors discovered the "grapefruit effect"—the fact that drinking grapefruit juice affects the way certain blood pressure medications work. More than 40 different meds can have their effects magnified by grapefruit juice. "

However, orange juice and apple juice could also interfere with some medications. The medication effect could be either increased or decreased.

In a study, healthy volunteers who took fexofenadine and drank grapefruit, apple or orange juice had decreased absorption of fexofenadine. Grapefruit decreased absorption the most.

This means that fexofenadine (Allegra) may not have the same effect if a patient takes it with grapefruit, apple or orange juice.

References:
Fruit juice and medications don't mix. ConsumerReports.
Image source: Wikipedia, public domain.

Rate of systemic reactions during subcutaneous immunotherapy: 0.28% per injection

A retrospective chart review at a single institution included 388 patients who had 10,497 subcutaneous allergen immunotherapy (AIT) injection visits during a 2-year period.

The rate of systemic reactions 0.28% per injection visit and 7.4% per patient (25 patients).

It was concerning that 48% of the systemic reactions occurred more than 30 minutes after the injection and many of these reactions required epinephrine.

This study was unable to identify risk factors that predict the reactions. Gender, phase (build-up versus maintenance), asthma, angiotensin-converting enzyme inhibitors, beta-blockers, initial skin-prick test size, or allergen type did not increase the odds of a systemic reaction.

Skin prick testing (SPT) on beta-blockers was safe in 199 patients in a 2012 study (http://goo.gl/3vGSl). However, incidence of systemic reactions is 1:250 with SPT.

References:

Allergen immunotherapy safety: Characterizing systemic reactions and identifying risk factors. Rank, Mathew A.; Oslie, Corrine L.; Krogman, Jennifer L.; Park, Miguel A.; Li, James T. Allergy and Asthma Proceedings, Volume 29, Number 4, 7/8 2008 , pp. 400-405(6).

The most recent SCIT-related fatal reaction occurred in 2007 - AAAAI http://goo.gl/k2QaN
Image source: OpenClipArt.org, public domain.

Study: No Evidence of Depression or Suicide Linked to Montelukast (Singulair)

In 2007, there were some concerns that suicide may be a complication of montelukast (Singulair) therapy.

Montelukast has been prescribed for more than a decade for the treatment of asthma and seasonal allergic rhinitis.

A retrospective study sponsored by the American Lung Association has found no evidence of depression or suicide linked to montelukast.

Among the 569 patients randomly assigned to take montelukast, there was no evidence of any deterioration of emotional well being in either adults or children. On the contrary, the researchers found a positive effect on emotional outlook.

The study findings will be published in an upcoming issue of the Journal of Allergy and Clinical Immunology.

Singulair was Merck's biggest product last year and the most-prescribed respiratory drug in the U.S., with worldwide sales of $ 4.27 billion. In 2007, included reports of tremors, depression, suicide and anxiousness in the drug's prescribing information.

Leukotriene Receptor Antagonists (LTRA)

Antagonists of the CysLT1 receptor (LTRA) are efficacious as controller therapy in asthma and montelukast is FDA-approved for treatment of seasonal allergic rhinitis.

Mast cells quickly generate different mediators from the metabolism of arachidonic acid: leukotrienes and prostglandins (LTC4, LTB4, PGD2). These substances are produced within minutes of IgE-receptor crosslinking on the surface of mast cells.


Eicosanoids are signaling molecules made by oxygenation of 20-carbon essential fatty acids. There are 4 families of eicosanoids (PP-LT): prostaglandins (PG), prostacyclins (PGI), leukotrienes (LT) and thromboxanes (TX).


Mast cell mediators including (PP-LT): prostaglandins (PG), prostacyclins (PGI), leukotrienes (LT) and thromboxanes (TX). See more Allergy and Immunology mind maps here.

References:
American Lung Association Study Finds No Evidence of Depression or Suicide Linked to Asthma and Allergy Drug Montelukast. MarketWatch, 09/2008.
Singulair (montelukast) and Suicide Risk

Urinary leukotriene E(4)/exhaled nitric oxide ratio predicts montelukast response in childhood asthma http://goo.gl/i5cG
Image source: Montelukast, from Wikipedia, the free encyclopedia, public domain.

Using Evernote as Electronic Medical Records Software

From EfficientMD:

Let me be clear: I'm not suggesting that Evernote is a substitute for any of the excellent commercial EHRs currently available. The following is presented as a proof of concept only for how a simple, inexpensive, customizable EHR built on Evernote might work.

Evernote has confirmed by email that, "At this time we do not plan to pursue HIPAA certification for our (consumer) Evernote service."

Of course, if you're concerned about transmitting information to the Evernote servers, you can always instruct Evernote to keep all data on your local computer. This bypasses the HIPAA issue and you'd still be able to use Evernote, but this means that you won't be able to access patient data from the web unless you use a program like GoToMyPc.com.

References:
How Doctors Can Use Evernote As A Professional Memory Accessible Anywhere, Part 2: Using Evernote as an Electronic Health Record (EHR). EfficientMD, 08/2008.