A Pragmatic Primary Practice Approach to Using Specific IgE in Allergy Testing in Asthma Diagnosis, Management, and Referral

Figures & data

Box 1 Barriers to Implementation of Asthma Management Strategies from the Global Initiative for Asthma (GINA)

Health Care Providers

● External barriers (national policies, organizational, cost) ● Lack of time and resources ● Insufficient knowledge of guideline recommendations ● Lack of agreement with or confidence in recommendations ● Resistance to change ● Medical-legal issues

People with Asthma

● Low health literacy ● Insufficient understanding of asthma and its management ● Lack of agreement with recommendations ● Cultural and economic barriers ● Peer influence ● Attitudes, beliefs, preferences, fears and misconceptions

Notes: GINA ©2022 Global Initiative for Asthma, reprinted with permission. Available from www.ginasthma.org.⁹

Box 2 Recommendations from ERS/EAACI Investigations of Allergy/Asthma Care

Adherence to Adult International Asthma Guidelines^Citation17

Implementation of guidelines is different across different asthma management settings. Guideline recommendations need to account for differences in resource availability across the various asthma care settings, including primary care. Continuous multifaceted quality improvement processes can improve guidelines adherence. Additional input from specialised health professionals could also be effective towards improving guidelines adherence. However, this is unlikely to be sustainable unless long-term funding is available. Locally agreed referrals to specialists are crucial both for generalists and specialists from different disciplines who have different approaches to diagnostic uncertainty and managing patients with poorly controlled asthma. More data are needed to evaluate differences in process and clinical outcomes among patients managed by generalists or specialists and to facilitate standardisation in the indications for referral of patients for specialist review.

Allergy Educational Needs in Primary Care^Citation18

1. There is inadequate allergy training of primary care providers at the undergraduate and postgraduate level. 2. There is an overall lack in primary care provider confidence in management of certain allergic conditions, understanding the basic principles underpinning key allergy process and in providing advice relating to anaphylaxis and adrenaline use. 3. There is variability across different European countries with regards to many aspects of allergy training, confidence and management. 4. While there is some awareness of local allergy guidelines for primary care providers, there is minimal awareness of EAACI guidelines across all countries.

Notes: Adherence to Adult International Asthma Guidelines is reproduced with permission of the ERS 2022. European Respiratory Review 30 (161) 210132; DOI: 10.1183/16000617.0132-2021 Published 15 September 2021 This version is distributed under the terms of the Creative Commons Attribution Non-Commercial Licence 4.0.¹⁷ Allergy Educational Needs in Primary Care is reproduced with permission from Cabrera M, Ryan D, Angier E, et al.Current allergy educational needs in primary care. Results of the EAACI working group on primary care survey exploring the confidence to manage and the opportunity to refer patients with allergy. Allergy. 2021;77(2):378–387. © 2021 EAACI and John Wiley and Sons A/S. Published by John Wiley and Sons Ltd.¹⁸

Figure 1 Pragmatic approach to aeroallergen testing and referral to asthma specialists.

Notes: Reproduced from J Allergy Clin Immunol Pract, 8(8), Casale TB, Pedersen S, Rodriguez Del Rio P, Liu AH, Demoly P, Price D. The role of aeroallergen sensitization testing in asthma management. 2526–2532, copyright 2020, with permission from Elsevier.⁵⁹

Box 3 The Modified Asthma Predictive Index

Stringent Asthma Predictive Index: ≥4 episodes of wheezing per year during the first 3 years of life and  ● At least 1 major or  ● At least 2 minor criteria
Major Criteria	Minor Criteria
1. Parental physician-documented asthma 2. Physician-diagnosed atopic dermatitis 3. Allergic sensitization to at least 1 aeroallergen	1. Wheezing unrelated to colds, reported by the parents 2. Peripheral eosinophilia ≥4% in circulation 3. Allergic sensitizations to milk, egg, or peanuts

Notes: Reprinted from J Allergy Clin Immunol Pract. 1(2). Chang TS, Lemanske RF Jr, Guilbert TW, et al. Evaluation of the modified Asthma Predictive Index in high-risk preschool children. 152–156, Copyright (2013), with permission from Elsevier.²¹

Box 4 Studies Supporting Allergen Mitigation Measures

Study	Results
Parikh et al 2018^Citation41	For children with asthma hospital admissions, a post-discharge referral for environmental mitigation programs, as part of comprehensive discharge education, helped reduce hospital readmission rates.
Murray et al 2017^Citation42	In children with asthma, a year-long study of dust mite-impermeable bed covers found a significant reduction in severe exacerbations requiring hospitalization, but no difference in the number of exacerbations.
Rabito et al 2017^Citation43	In homes of children with asthma, a simple cockroach-specific intervention with insecticide bait reduced asthma severity (eg, symptom burden), and modestly affected exacerbations.
Kercsmar et al 2006^Citation44	In children with asthma, home remediation of dampness and mold demonstrated a significant reduction in exacerbations.
Shirai et al 2005^Citation45	For people of all ages, one small (n=20) study of pet removal from homes of pet-allergic people with asthma demonstrated significant improvement, largely attributable to reduction in pet rodent or ferret exposure, not exposure to cats or dogs.
Morgan et al 2004^Citation46	In inner-city children with asthma who were cockroach-sensitized, a multifaceted intervention including establishing an environmentally safe sleeping zone, significantly reduced cockroach, dust mite, and cat allergen exposures, significantly reduced asthma symptom days and nights, decreased missed school days, emergency department and unscheduled office visits. Significantly reduced asthma symptoms continued during the year after the study ended.

Box 5 Advantages of Skin or in vitro Testing

Skin Testing	In vitro Testing
● Less expensive than in vitro tests. ● Results are available within 1/2 hour. ● Equally sensitive as in vitro tests. ● Results are visible to the patient. This may encourage compliance with environmental control measures.	● Does not require knowledge of skin testing technique. ● Does not require availability of allergen extracts. ● Can be performed on patients who are taking medications that suppress the immediate skin test (antihistamines, antidepressants). ● No risk of systemic reactions. ● Can be done for patients who have extensive eczema.

Notes: From Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol 2007;120(5 Suppl):S94–138. National Institutes of Health. Available from: https://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-report .⁵

Box 6 Measurements Used by Specialists to Differentiate Asthma Phenotypes

Eosinophilic Asthma

Sputum eosinophil count of ≥1% or  Blood eosinophil count of ≥150 cells/uL^a or  FeNO of ≥20 ppb

Allergic Asthma

Asthma symptoms due to exposure to aeroallergens  Proven IgE sensitization to these aeroallergens  Total sIgE 30–1300 IU/mL

Notes: Data from Agache I, Akdis CA, Akdis M et al. EAACI Biologicals Guidelines-Recommendations for severe asthma. Allergy. 2021;76(1):14–44.^{49 a}This is the blood eosinophil count used by the European Academy of Allergy and Clinical Immunology (EAACI), and other groups may use different counts.

Global Initiative for Asthma. Pocket guide for implementing asthma management strategies into health care; 2018. Available from: https://ginasthma.org/wp-content/uploads/2019/02/GINA-Implementation-Pocket-Guide-2019.pdf. Accessed March 13, 2020.

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