1 allergy and asthma: improving outcomes in primary care len fromer, m.d., faafp...

1

Allergy and Asthma: Improving Outcomes in Primary Care

Len Fromer, M.D., FAAFP

AsthmaWRAP—SlideCASTAsthmaWRAP—SlideCAST

2

The Etiology ChallengeThe Etiology Challenge

► Common symptoms and diseases have many possible etiologies

► IgE-mediated allergies triggersymptoms from infancy into adulthood

► Identification of true underlying cause is essential for effective management

3

The Allergic Inflammatory ResponseThe Allergic Inflammatory Response

4

Common Childhood DiseasesCommon Childhood Diseases

►The illnesses of the Allergy March Atopic dermatitis (eczema) GI distress Recurrent otitis media Allergic rhinitis Allergic asthma

►The symptoms Inflammatory in nature Multiple etiologies Treated empirically

5

The Allergy March: A Progression of Seemingly Unrelated Diseases

The Allergy March: A Progression of Seemingly Unrelated Diseases

AtopicDermatitis

GI Distress

RecurrentOtitisMedia

AllergicAsthma

AllergicRhinitis

Food Sensitivity

InhalantSensitivity

Time (~years)

Genetic Predisposition

6

0

10

20

30

40

50

Age (years)

Prevalence of Atopic Disease

1 3 5 10 17

Symptoms

Gastrointestinal Respiratory Skin

Pre

vale

nce

(%

)

Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069.

Allergy MarchAllergy March

7

Age (years)

0

1

2

3IgE Antibody Level

4 - 90 - 3 10 - 15

n= 12 29 12

Mea

n s

co

re(P

ha

de

ba

s R

AS

T C

las

s)

Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763.

Allergy MarchAllergy March

Birch pollen

Peanut

Egg white

8


► Atopic dermatitis (AD)1

17%-20% prevalence in US, other western countries

Not necessarily severe reaction (anaphylaxis)

Driven by early exposure and sensitization

40% of AD caused by food sensitivity

Empirical treatment: trials of topicals

1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573.

9


► GI distress1

Colic, diarrhea, vomiting, constipation, reflux

Multiple etiologies: – atopy, infection, intolerance, malabsorption, inflammatory

bowel, anatomic defect

10%-42% of symptomatic patients are atopic2,3

50%-60% of infants with food sensitivities show GI symptoms(not necessarily full-blown food allergy)

– Empirical treatment: trials of formulas

1. Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494. 2. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at:

http://www.allergy.org.au/aer/infobulletins/adverse_reactions.htm.3. Sicherer SH. Pediatrics. 2003;111:1609-1616.

10


► Recurrent otitis media (OM) 26% prevalence in US1

Key risk factors include attendance in daycare,cigarette smoke exposure2

40%-50% involve atopy3,4

Common underlying cause = eustachian tube dysfunction

– Caused by inflammation related to allergy or infection

– Recurrence = not treating the underlying cause

Empirical treatment: antibiotics, surgery

1. Lanphear BP, et al. Pediatrics. 1997;99:1-7.

2. AAAAI. The Allergy Report. 2000;2:155-161.

3. Data on file, Pharmacia Diagnostics.

4. Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797

11

Atopy’s Long-Term ConsequencesAtopy’s Long-Term Consequences

► Nearly 80% of children with AD go on to develop allergic rhinitis and/or asthma1

► Children with early and long-lasting food sensitization: 3x more likely to develop allergic rhinitis (AR) than those

transiently sensitized2

5x more likely to develop asthma than those transiently sensitized2

► Young wheezers with confirmed atopy are more likely to develop asthma3

1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573.

2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67.

3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174.

12

Knowledge of Etiology Guides Treatment for Today and TomorrowKnowledge of Etiology Guides Treatment for Today and Tomorrow

► Specific IgE testing in children can help the clinician:– Identify allergen sensitivities– Counsel for avoidance– Eliminate or reduce symptoms– Reduce medication use (including antibiotics)

► Targeting atopy can eliminate symptoms and interrupt the Allergy March1-5

– ETAC: Cetirizine and avoidance halved asthma risk in children with AD1

– PAT: Immunotherapy significantly reduced asthma risk in children with AR2

– CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence 56% in high-risk children5

1. ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124.2. Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256.3. Platts-Mills TAE. N Engl J Med. 2003;349:207-208.4. Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308.5. Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55.

13

Etiology Is ElusiveEtiology Is Elusive

Upper Respiratory Diseases

AllergicRhinitis

Non-allergicRhinitis Sinusitis

14

Overlapping SymptomsOverlapping Symptoms

Allergic Rhinitis

Nasal congestion

Rhinorrhea

Increased secretions

Sneezing

Itchy, watery eyes

Non-allergic Rhinitis

Nasal congestion

Rhinorrhea

Increasedsecretions

Postnasal drainage

Chronic Sinusitis

Nasal congestion

Rhinorrhea

Increased secretions

Postnasal drainage

Headache

Facial pain

15

Upper Respiratory DiseasesUpper Respiratory Diseases

► Allergic rhinitis, non-allergic rhinitis, sinusitis

► Symptoms caused by inflammation

Multiple etiologies, including:– Allergic • Hormonal – Anatomic • Vasomotor – Infectious

► Usually treated empirically/symptomatically

► Depending upon etiology, treatment can/should be different

16

Productivity Loss $ per 1000 EmployeesProductivity Loss $ per 1000 Employees

$1,436,292

$880,152

$520,884

$275,808$187,200 $148,512

$0

$500,000

$1,000,000

$1,500,000

Allergies Depression Hypertension

Respiratory Diabetes CV Disease

17

Comparison of Quality-of-Life in Asthmatic and Chronic Rhinitis Patients

Comparison of Quality-of-Life in Asthmatic and Chronic Rhinitis Patients

Mean Quality-of-Life Score (Scale 1-100)*

Health ConceptAsthma(n=252)

Chronic Rhinitis(n=111)

Social functioning 84 73

Physical functioning 80 89

Role limitations (emotional) 70 64

Role limitations (physical) 66 61

Energy/fatigue 59 55

Pain 74 77

Change in health (1 year) 55 50

18

Distribution of URD in US1-3Distribution of URD in US1-3

► 39% of total population (115M of 295M) have URD

1. AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023. 2. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16. 3. Allergy Statistics.AAAAI Web site. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm.

40M

35M

40M

Sinusitis30%

Non-allergicRhinitis

35%

Allergic Rhinitis35%

19

Actual Atopy and Antihistamine UseActual Atopy and Antihistamine Use

1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238.

Identification of allergic disease among users of antihistamines1

► Allergic rhinitis, non-allergic rhinitis, sinusitis

► Study of managed-care patients repeatedly prescribed oral antihistamines

► Convenience sample of 246 evaluated with in vitro allergy testing

► Results revealed non-atopicsymptom etiology in 2/3 of patients

35%Atopic

Etiology 65%Non-atopic

Etiology

20

Non-allergic RhinitisNon-allergic Rhinitis

► Wide array of types and etiologies1,2

Includes: infectious, vasomotor, hormonal, anatomic, occupational, drug-induced

► Not caused by IgE-mediated allergic inflammation

Non-sedating antihistamines and other allergy-targeted therapies will not treat underlying cause

1. AAAAI. The Allergy Report. 2000;2:1-31. 2. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518.

21

Allergic RhinitisAllergic Rhinitis

► Triggered by seasonal or perennial allergen(s)

► Symptoms may include: Nasal congestion, rhinorrhea, increased secretions, sneezing,

itchy nose/eyes, watery eyes, coughing, postnasal drip1,2

► Cumulative threshold disease3,4: Patients are rarely monosensitized Symptoms emerge after “allergic threshold” has been exceeded

1. AAAAI. The Allergy Report. 2000;2:1-31. 2. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518. 3. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01.4. Wickman M. Allergy. 2005;60 (Suppl 79):14-18.

22

Cumulative Threshold Disease1Cumulative Threshold Disease1

1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01.2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979.3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026.

Symptoms

Situation A2

No avoidancemeasures

Situation B3

No avoidancemeasuresThird allergen

Situation C3

Avoidance measuresemployedThird allergen

Cat dander

Dust mites

Ragweed

23

Support for Avoidance in the Management of Allergies and Asthma

Support for Avoidance in the Management of Allergies and Asthma

► …It has become clear that early intervention may modulate the natural course of atopic disease…the reduction in exposure of high-risk infants to food and house-dust mite allergens substantially lowers the frequency of allergic manifestations in infancy.”1 – Halmerbauer, et al.

► “Extensive experience suggests that both drug treatment and immunotherapy are more effective if patients also decrease exposure. The approach is to identify the allergen source (or sources) to which the patient is allergic and to educate patients extensively.”2 – Platts-Mills, et al.

► The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone of asthma management3-5

1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17.2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 .3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051.4. AAAAI. The Allergy Report. 2000;2:33-109. 5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13

24

SinusitisSinusitis

► Multiple etiologies Caused by inflammation from infection, allergy, structural

abnormalities,other causes1

ENT experts use term “rhinosinusitis” due to epithelial continuum

of sinus/nasal passages1,2

► Common comorbidity–often with atopy Rarely occurs without concurrent rhinitis2 >50% of moderate to severe asthmatics have chronic

rhinosinusitis3

1. Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20. 2. AAO-HNS. Fact sheet. ENT Link Web site. Available at: http://www.entnet.org/healthinfo/sinus/allergic_rhinitis.cfm. 3. AAAAI. The Allergy Report. 2000;2:7,137-153.

25

Why Should You Test?Why Should You Test?

► History and physical alone yield a correct diagnosis only 50% of the time1

► Different etiologies demand different treatment approaches

► Testing for specific IgE levels can rule in/out atopy

► If atopic: – NSAs probably drug of choice– Testing can help clinician pinpoint offending allergens

► If non-atopic:– Results will allow you to focus on other etiologies– Drugs of choice may include decongestants/steroids– Patient can avoid unnecessary/ineffective treatment

1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031.

26

URD Management OptionsURD Management Options

Specific IgE-Positive/Abnormal Atopic Etiology

Specific Allergen Avoidance

AdequateResponse

Allergy-TargetedPharmacotherapy(eg, NSAs, LTRAs)

Stop

Inadequate Response

Referral?

Inadequate Response

Specific IgE-Negative/Normal Non-Atopic Etiology

AdequateResponse

Pharmacotherapy(allergy-targeted

Rx not helpful)

Stop

Inadequate Response

Referral?

27

The Experts on Differential Diagnosis of RhinitisThe Experts on Differential Diagnosis of Rhinitis

“A positive diagnosis (or diagnoses) should be made before formulating

management.”1

1. Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007.

28


► An expert panel in the area of allergy diagnosis recommended selective use of in vitro allergy testing by primary care physicians.

► According to these experts, in vitro tests1:

Offer a well standardized alternative to skin testing

Are easily used by generalist physicians

Are effective in the diagnosis of allergy

1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412.

29


“Allergy [IgE] testing should be considered in all patients with a suspected diagnosis

of allergic rhinitis.”1

1. Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB Sanders Company; 1995:403-404.

30

Etiology Linked to TriggersEtiology Linked to Triggers

31

Overlapping SymptomsOverlapping Symptoms

“All that wheezes is not asthma.” – Chevalier Jackson [1865-1958]

Allergic Asthma

Wheezing

Cough

Dyspnea

Chest tightness

Rhinitis

Conjunctivitis

Non-allergic Asthma

Wheezing

Cough

Dyspnea

Chest tightness

“Bronchitis”

Wheezing

Cough

Dyspnea

32

Lower Respiratory DiseasesLower Respiratory Diseases

► Course and severity affected by inflammation (often caused by allergy)

► Underlying atopy shown to increase symptoms and precipitate exacerbations

► A wide range of possible triggers include: Allergy Occupational exposures Infection GERD Tobacco smoke Emotional stress Exercise Cold weather

33

AsthmaAsthma

► Widespread 7% prevalence (>20 million1) and rising 73% managed by PCPs2

► Allergic vs. non-allergic asthma 60% of asthmatics have allergic asthma3

90% of children with asthma also have allergies4

1. NCHS. Asthma prevalence, health care use and mortality 2002. Available at: http://www.cdc.gov/nchs/Default.htm.2. NCHS. Ambulatory care visits 1999–2000. Available at: http://www.cdc.gov/nchs/Default.htm.3. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003. 4. HØst A, Halken S. Allergy. 2000;55:600-608.

34

The “One Airway” ConceptThe “One Airway” Concept

► Common inflammatory process links upper and lower airways1

Asthma and allergic rhinitis commonly co-exist2,3

In concomitant disease, experts recommend evaluation and treatment of one condition to aid management of the other4

Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6 and AAAAI7 encourage treatment of AR (and other URDs) to help control asthma

1. Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43.2. Nayak AS. Allergy Asthma Proc. 2003;24:395-402. 3. Halpern MT, et al. J Asthma. 2004;41:117-126.4. Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855.5. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051.6. AAFP. Asthma & Allergy Resource Guide. 2004:18.7. AAAAI. The Allergy Report. 2000;2:33,54.

35

NIH Asthma Guidelines1NIH Asthma Guidelines1

Trigger identification/control is primary management step

► “For at least those patients with persistent asthma on daily medications, the clinician should:

Identify allergen exposures

Use the patient’s history to assess sensitivity to seasonal allergens

Use skin testing or in vitro [blood] testing to assess sensitivity to perennial indoor allergens

Assess the significance of positive tests in contextof the patient’s medical history”

1. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051.

36

NIH Asthma Guidelines1 (cont’d)NIH Asthma Guidelines1 (cont’d)

► “Use skin testing or in vitro testing to determine the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed year round.”

► Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.”

► For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.”

1. NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051.

37

Knowledge of Symptom Triggers Guides ManagementKnowledge of Symptom Triggers Guides Management

► Allergy testing may be conducted along with pulmonary function tests and other diagnostic evaluations1

► In allergic asthma: Confirm atopy and identify specific allergic triggers for avoidance

counseling, symptom reduction, and control of severity and comorbid AR

► In non-allergic asthma: Rule out atopy to focus on possible non-allergic triggers Prevent needless control measures

1. NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053.

38

Asthma Management OptionsAsthma Management Options

Specific IgE-Negative/NormalNon-Atopic Etiology

Referral?

InadequateResponse

AdequateResponse

Pharmacotherapy• Allergy Rx not helpful • Controller(s)• Rescue Rx

Stop

Focus on Non-allergic Triggers

Specific IgE-Positive/Abnormal Atopic Etiology

Specific Allergen Avoidance

AdequateResponse

Pharmacotherapy • Treat AR (eg, NSAs)• LTRAs• Controller(s)• Rescue Rx

Stop

Inadequate Response

Referral?

Inadequate Response

39

What Is Happening to Treatment?What Is Happening to Treatment?

► Mechanism of disease is better understood

Means that treatments are nearer the root cause

► Therapeutic specificity is increasing

Diseases are different and differentiation is key

The mechanism of action of drugs is more specific than ever

Diagnostic precision by PCP is necessary– New diagnostic technology must be employed

40

Market Review: The Role of Diagnostics in Pharmacotherapy

Medications for Respiratory Allergy

$$$$$$

Highly specifictreatment

Highly specific resolution of symptoms

due to IgE response only — necessitates

perfect diagnosis

Binds to IgE;Suppression of IgE

response

Anti-IgE Vaccine(2003)

$$$

Very specific to atopy — necessitates even more accurate diagnosis (Doctors

report marginal response for AR with

Singulair — could be 65% are not allergic)

Specific resolution of symptoms of

atopy by blocking another

mediator pathway

Leukotriene antagonist

Montelukast(2002)

$$

Introduction of “D” formula creates

less specific treatment

More specific resolution of symptoms primarily due to atopic

etiology — necessitates more specific diagnosis

Antihistamine effect with very little

anticholinergic effect

Non-sedatingAntihistamines

(1990s)

$

Broad (shotgun)

Non-specific resolution

of symptoms regardless of

etiology

Antihistamine effect +

Anticholinergic effect

1st GenerationAntihistamines

(1970s)

Cost

Therapeutic Approach

Treatment Results

Mode(s) of Action

TreatmentProgression

41

Disease ParadigmsDisease Paradigms

Hx & PE lab tests diet & exercise pharmacotherapy

Diabetes Mellitus Type 2

Hx & PE lipid profile diet & exercise pharmacotherapy

Hypercholesterolemia

Hx & PE pharmacotherapy

CHDs, URDs, LRDs

?IgE profile avoidance

42

In-vitro Testing: Gain Knowledge to Guide TreatmentIn-vitro Testing: Gain Knowledge to Guide Treatment

► FDA-cleared quantitative measure of specific IgE

► Only a single blood draw required

► Covered under most insurance plans

► Accuracy superior to RASTTM*1

Next-generation assay offers consistently improved sensitivity,2

De facto standard, documented in >2,700 peer-reviewed publications3

► In vitro blood testing and skin prick testing (SPT) viewed as interchangeable4

► In-vitro testing is available throughout the nation from all major reference and clinical laboratories, including Quest Diagnostics, NS-LIJ & BioReference

* RAST is a trademark of Pharmacia Diagnostics.1. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230.2. Szeinbach SL, et al. Ann Allergy Asthma Immunol. 2001;86:373-381.3. Johansson SGO. Expert Rev Mol Diagn. 2004;4:273-279. 4. Hamilton RG. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:233-242.

43

H. Drevin, 1989A. Kober, 2004

Solid-phase Protein Binding Capacity ComparisonSolid-phase Protein Binding Capacity Comparison

Solid Phase

• cellulose polymer binds almost 150 times more protein than a passively coated tube, well or bead, and about 250 percent more protein than a paper disc.

44

Accuracy of Immunoassays for Specific IgEAccuracy of Immunoassays for Specific IgE

*The authors noted that regression values below 0.80 reflect poor performance in the ability to correctly detect levels of specific IgE antibodies. ONLY CAP RAST had consistently acceptable regression values.**Alastat was recently replaced by 3gAllergy. Studies show 93% agreement between both methods.

Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230.

Line represents minimum acceptable R2

performance values

Alastat/3gAllergyTM**

RAST/Modified

RAST

Newest generation:In-vitro testing

Ideal Test (Correlation Coefficient)

.65

.82

.96 - .981.0

45

Predictive Value vs. Skin Prick Testing (SPT)*Predictive Value vs. Skin Prick Testing (SPT)*

Performance parameters In vitro† SPT

Sensitivity (%) 87.2 93.8

Specificity (%) 90.5 80.1

PPV (%) 91.1 90.1

NPV (%) 86.4 87.1

Clinical Efficiency (%) 88.8 89.2

*Adapted from Reference 1.†in-vitro Specific IgE blood test was used in this study.1. Wood RA, et al. J Allergy Clin Immunol. 1999;103:733-779.

• Authors concluded that In-vitro testing Specific IgE blood test and SPT values both exhibited excellent efficiency1

46

Profiles Carefully DesignedProfiles Carefully Designed

► Profiles engineered to detect >95% of patients with allergy1-3

► Regional respiratory profiles include key indoor/outdoor allergens selected according to: Geographic pollen patterns Regional disease prevalence Cross reactivity to other allergens in each inhalant class

► Allergy March profiles include key food/inhalant allergens Six foods account for 90% of food allergy reactions in children4

Inhalants include common/cross-reactive indoor and outdoor allergens Generally recommended for children ≤6 years of age, based on symptoms

1. Sampson HA, Ho DG. J Allergy Clin Immunol. 1997;100:444-451.2. Yunginger JW, et al. J Allergy Clin Immunol. 2000;105:1077-1084. 3. Poon AW, et al. Am J Man Care. 1998;4:969-985. 4. AAAAI. The Allergy Report. 2000;3:69.

47

Understanding Total IgE1Understanding Total IgE1

► Total IgE often of little practical value when considered alone

► Levels rarely high when specific IgE titers are not

► Lacks sensitivity as a rule-out screen: Specific IgE levels may be significantly high when total IgE is low/normal

► Extremely high total IgE may be seen in some very rare non-atopic conditions2: Certain immunodeficiency diseases (including HIV)

IgE myeloma

Drug-induced interstitial nephritis

Graft-versus-host disease

Parasitic diseases

Skin diseases in addition to eczema

Hyper-IgE syndrome (dermatitis, recurrent pyogenic infection)

1. Fromer LM. J Fam Pract. 2004;suppl:S4-S14.

2. AAAAI. The Allergy Report. 2000;1:35.

48

Understanding Total IgEUnderstanding Total IgE

*Includes URDs (Upper Respiratory Diseases), CHDs (Childhood Diseases), and LRDs (Lower Respiratory Diseases)

1. AAAAI. The Allergy Report. 2000;1:35.12

Interpretation of Total IgE* Results

Negative(Normal)

Positive(Abnormal, Elevated)

Negative(Normal)

Positive(Abnormal,Elevated)

Non-allergic Patient

Scenario A

Rare1

Scenario B

Allergic Patient

Scenario C

Allergic Patient

Scenario D

Sp

eci

fic I

gE

Re

ad

ing

Total IgE Reading

49

SummarySummary

► Diagnostic precision leads to evidence-based medical care

Improves patient care

Creates better patient satisfaction

Provides more appropriate referrals

► In-vitro testing Specific IgE blood test is an accurate test to differentiate atopic from non-atopic patients

► Experts, specialty organizations, and government agencies support allergy testing in primary care

50

URD Inhalant

Panel

Interpretation

Of

Results

51

Allergy and Asthma: Improving Outcomes in Primary Care

Len Fromer, M.D., FAAFP

AsthmaWRAP—SlideCASTAsthmaWRAP—SlideCAST

1 allergy and asthma: improving outcomes in primary care len fromer, m.d., faafp...

Documents