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Allergy Education

The mission of Wellspring Medical Services, regarding allergy treatment, is to assist and facilitate the development of an effective and profitable ancillary service in your practice.

Our Mission

By the end of the course, participants will • Gain an understanding of allergies and how they are effecting

the medical condition of your patients • Understand proven solutions to test & treat patients who suffer

with allergic disease • Understand how an allergy program works • Understand patient safety during allergy testing & treatment • Understand how an allergy program can be successfully

implemented (Managers/Owners only)

Course Objectives

What is an allergy?

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Schatz M, Allergy 2007: 62 (Suppl.85): 9-16

Survey of Allergic Rhinitis in USA

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Gaugris, et al. J Asthma 2006; 43: 1-7 Prieto JL Clin Exp Allergy 1996;26(1): 61-67 Meltzer EO Allergy Asthma Proc 2005;26:334-340

What percentage of the patients in your practice has allergic disease?

• Allergic rhinitis 15-40% of population • Asthma 7% of population

• 50-100% of patients with asthma have AR • 20-40% of patients with AR have Asthma

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Allergic Rhinitis: Specific Triggers • Pets: cats, dogs, rabbits, hamsters, horses, • Home or work/school: moisture problem,

poorly maintained A/C or indoor air turnover, cockroach exposure, carpets

• Symptoms worse in specific areas: garden, hobby, sport, smoky bars

• Non-allergenic irritants: fragrances, smoke, chemicals, change in temp/humidity

• Outdoor airborne: grasses, trees, weeds

The relationship of allergies to other common conditions • Asthma • Sleep Disordered Breathing • Nasal Obstruction • Chronic Rhinosinusitis • Rashes, Hives, Eczema

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Allergies & Asthma

Mullarkey MF. J Allergy Clin Immunol . 1980;65:122-126. Smith JM. In: Middleton E, et al, eds. Allergy: Principles and Practice . 3rd ed. St. Louis, Mo: CV Mosby Company; 1988;2:891-929.

• Allergic rhinitis 15-40% of population • Asthma 7% of population • 50-100% of patients with asthma have AR • 20-40% of patients with AR have asthma

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Asthma Impact • 26 million asthmatics ( 8.6 million children) • > 20 million outpatient visits per year • > 1.8 million ED visits per year • > 500,000 hospitalizations per year • > 20 million lost work days per year • > 14 million lost school days per year • > 35 million prescriptions per year • Nearly 5000 deaths per year

Stelmach R, et al. CHEST 2005; 128:3140–3147 Malick A, Grant JA. Allergy. 52(34 Suppl):55-66, 1997. Niggemann, et al. Allergy 2006;61:855-859. F

Allergy & Sleep Disorders Two Causes of Sleep Disturbance in AR

–Obstructive model • Nasal obstruction interferes with nasal breathing • – Arousals/awakenings 2º to obstruction

– Inflammatory dysregulation model • Inflammatory mediators disrupt sleep on a

central level

Craig et al., J Allergy Clin Immunol , 2005;116:1265 F

Allergy & Mouth/Voice Problems • Mouth Breathing Inhalant allergies can affect voice by : • Excess secretions (PND, tracheal & • locally generated) • Direct local reaction (vocal fold

edema, as with Reinke’s) • Laryngeal drying from mouth

breathing

Corey J et al. Otolaryngol Clin N Am 1998;31:189-205 Jackson-Menaldi C, et al. Log Phon Vocol 2002;27:74-79

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Allergy & Sleep Disorders • Mechanical obstruction of the airway leads to

increased nasal airway resistance • Disruption in normal breathing leads to

awakenings and arousals • Many inflammatory mediators are involved in

the regulation of sleep • Histamine • Cysteinyl leukotrienes • Prostaglandins • Cytokines

Craig et al., J Allergy Clin Immunol , 2005;116:1265 F

Allergy Symptoms: Skin • Dry, scaly skin, ranging from dandruff to

lichenification • Pruritis is characteristic (signs of scratching) • Varies from eczema, contact dermatitis &

urticaria to angioedema

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Allergy Treatment

Immunotherapy Introduction • “We cannot control the effects of all stimulation

from our external environment. • Our body has the ability to inhibit the effects of

certain types of stimulation, if the stimulation schedule is regular, smooth, and without abrupt changes in stimulus intensity.

• Such is ...immunotherapy, where the body is regularly exposed to an antigenic stimulus.”

Haydon RC, Gordon B Aerollergen injection immunotherapy. In: Gordon B, Krouse J, Derebery J, Chadwick S, eds. Allergy and Immunology: An Otolaryngic Approach. Phil.: Lippincott Williams and Wilkins: 2001. F

Early Days of Immunotherapy • Koessler (1914) demonstrated

tolerance to pollen challenge after immunotherapy

• Used a measurably safe, progressive, and reproducible escalation of doses

• The benefits of IT were shown to alleviate allergy symptoms, following one or two years of therapy

Koessler KK. The specific treatment of hayfever by active immunization. Illinois Med. J. , 1914; 25:120-127.

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Treatment Options for Allergy

Koessler KK. The specific treatment of hayfever by active immunization. Illinois Med. J. , 1914; 25:120-127.

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The Goal of Immunotherapy • The goal of immunotherapy is to escalate antigen dose to the point of highest tolerated dose • This dose should also control symptoms without causing unacceptable local or systemic reactions

Otolaryngol Head Neck Surg 1995; 113:597-602 F

Efficacy of Immunotherapy Since 1954, 22 of the 26 best-designed, double-blinded clinical trials have shown efficacy: • 18/21 showed either

• Increased sp IgG • Decreased sp IgE, or both

• 9 studies that measured change in skin testing • 4 showed no change, • 5 demonstrated decreased skin reactivity

• 6/7 studies demonstrated • decreased nasal, or • conjunctival reactivity

Bierman, et al Allergy, Asthma, and Immunology from Infancy to Adulthood

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Efficacy of Immunotherapy in Asthma/Rhinitis: Meta-analysis • Assessed >40 controlled rhinitis studies from 1980 - 1998

• Significantly greater improvement in clinical symptoms in the active group in approximately 80% of studies

• Assessed >16 controlled asthma studies published since 1980

• Clinically relevant efficacy reported in 11/16 (69%)

Malling HJ. Immunotherapy as an effective tool in allergy treatment. Allergy. 1998;53:461-472.

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Development of Asthma in Patients with Allergic Rhinitis on IT

1 Lombardi C. Respir Med . 2001;95:9-12. 2 Jacobsen L. Allergy. 1997;52:914-920. 3 Valloviirrtta E.. J Investig Allergol Clin Immunol .. 1997;;7::369--370.. 4 Yang X.. Drugs.. 2001;;61::365--374 .. F

Adding Allergy Program to your Practice

Why Test for Allergies?

• Confirm the presumptive diagnosis of allergies • Identify specific allergens • Determine the level of the patient’s sensitivity • Correlate the findings with the clinical picture • Necessary when considering immunotherapy

Malling HJ. Immunotherapy as an effective tool in allergy treatment. Allergy. 1998;53:461-472.

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Scratch Test Based Immunotherapy • Commonly used for the diagnosis

of inhalant allergy and the provision of immunotherapy.

• With a vial test, immunotherapy based on prick testing alone can be safe and effective.

• If prick positive, start treatment as #6 endpoint. (c/w MQT approach).

Skin Testing for Inhalant Allergy: Current Strategies. AAOA Monograph; John H. Krouse, Richard L. Mabry, MD

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Treatment Board Preparation •Make up five-fold dilutions 1-6 •The treatment board diluent choice is usually phenolated saline (PNS)

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Allergy Coding & Reimbursement Challenges

• Not all carriers recognize all testing techniques • Some carrier policies restrict allergy testing • In 2008 many medical polices were revised to

include non-coverage of SLIT (not yet FDA approved)

• Most common payment denial – inadequate documentation!

Typical Allergy Program Problems

• Some Patients will fail to understand immunotherapy or will get frustrated with slow results

• Some Patients will quit mid-treatment • Some Patients will fail to remain compliant to the

program • Some Patients will fail to understand costs/copays,

etc…

Managing Allergy Risk

Immunotherapy Risk

• Anaphylaxis is the most important risk in allergy immunotherapy

• Reactions occur in up to > 36% in rush and cluster protocols (which we do not do)

• Technique determines risk

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Immunotherapy Risk

• In 1994, U. S. Food and Drug Administration estimated U.S. death rate from immunotherapy to be 0.7 deaths per million injections (0.00007%)

Turkeltaub PC. Deaths associated with allergenic extracts. FDA Med Bull 1994; May:7

Immunotherapy Risk Study

Hurst DS, Gordon BR, Fornadley JA, Hunsaker DH. Safety of Home Based and Office Allergy Immunotherapy: a multicenter prospective study. Otolaryngol Head Neck Surg 1999; 121:553-561

Study Design

• Prospective 12 month study • SCIT • 27 U.S. medical offices • AAOA Fellows, in practice for 5 - 15 years • 635,600 visits and 1,144,000 injections


Study Goals

• Determine the degree of safety • Compare safety of home and office treatment • Identify all risk factors


Systemic Reactions


Risk Management • Risk Factor for Major Reaction: Active Asthma

• Moral: ask each patient about their condition before each injection. • Risk Factor for Major Reaction: New Vial - First Shot

• Moral: Use a vial test when beginning a new vial. • Risk Factor for Major Reaction: Errors

• Moral: Use a vial test when beginning a new vial & give careful dose instructions for home injections.

• Risk Factor for Major Reaction: Beta Blocker treatment • Some experienced allergy providers do cautiously treat these patients

Hurst DS, Gordon BR, Fornadley JA, Hunsaker DH. Safety of Home Based and Office Allergy Immunotherapy: a multicenter prospective study. Otolaryngol Head Neck Surg 1999; 121:553-561 L

Treatment for Anaphylaxis • We will call provider for help • Tourniquet above & lidocaine with epinephrine at injection site • Patient supine or in Trendelenburg • Administer epinephrine (Provider) • ABCs, prepare for airway management • Prepare Oxygen for Administration • Give bronchodilator inhalers • Give H1 & H2 antihistamines, steroids, heparin as needed (Provider) • Establish IV; start rapid infusion (Provider)

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Conclusion • Allergic Rhinitis is common. • Allergic Rhinitis affects Asthma, some skin diseases and other symptoms. • Allergies are treatable. • Immunotherapy in the only treatment that improves the patient’s own

immune response. • Immunotherapy has been demonstrated to be both effective and safe. • Immunotherapy will improve the health of many patients. • Immunotherapy can safely and profitably be incorporated into your practice.

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Making Your Allergy Program Work

Making Your Allergy Program Work

– The secret to making an allergy program successful is to agree upon a simple and repeatable patient flow process.

– Once this process has been established, communicating any necessary changes to keep the program working correctly

Allergy Program Success Key #1

– Include an allergy “page” in your new-patient forms.

– Review: Chart Update Form – Give these forms to us and we will verify, call

and schedule.


– When taking patient vitals & reviewing medical history MA asks,

“Do you have allergies such as; hay fever, rashes, stuffy nose, or sinus problems?”


– MA makes a quick note on the chart (A+ or A-).


– Provider asks: “I see you are suffering with allergies. Could you please tell me about that?”


– Provider walks the patient down the hall to the allergy testing room.

– Or… give a copy of the A+ (patients with allergies) charts to us and we will verify, call & schedule

taining allergy education - amazon s3 › clippingsme-assets › ... · • allergic rhinitis...

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