OHSU Internal Medicine UpdatesReview in Allergy Internal Medicine Review – April 12th, 2019 Shyam Joshi, MD Assistant Professor of Medicine Section of Allergy and Immunology Disclosures

• I have no actual or potential conflict of interest in relationOHSU to this presentation. Internal Medicine Review Objectives

• Characterize and stratify penicillin allergic reactions OHSU • Determine which patients should undergo penicillin allergy evaluations •InternalIdentify new areas of Medicine food allergy research and treatment options • Compare treatmentReview options for allergic rhinitis Presentation Outline

• Penicillin Allergy – Shenoy ES, etOHSU al. JAMA, 2019. • Food Allergies – Sampson HA, et al. JAMA, 2017. Internal– Bird, et al. J Allergy ClinMedicineImmunol Pract, 2018. • Allergic Rhinitis – Dykewicz MS,Review et al. Ann Allergy Asthma Immunol, 2017. Penicillin Allergy OHSU Internal Medicine Review Penicillin Allergy

• 8-10% of the US population carries a history of penicillin allergy • >95% will tolerateOHSU penicillin use after evaluation • Waning sensitivity to penicillin Internal• 50% lose sensitivity by Medicine 5 years • 80% lose sensitivity by 10 years • Subsequent penicillin use after negative testing does not increaseReview risk of sensitization

Sogn DD, Evans R, Shepherd GM, et al. Ann Intern Med. 1992. Gadde J, Spence M, Wheeler B, et.al. JAMA. 1993. Macy E, Contreras R. J Allergy Clin Immunol. 2014. Solensky R, Earl HS, Gruchalla, RS. Arch Intern Med, 2002. Dorman SM, Seth S, Khan DA. J Allergy Clin Immunol Pract, 2018. Effects of Penicillin Allergy Label

Use of inferior/toxic OHSUantibiotics

Increase in Increase in Internallength of stay Medicineadverse effects

ReviewAntibiotic resistance Antibiotic Exposure

Antibiotic Exposures in Hospitalized

PCN Allergy (N=51,582 OHSUhospitalizations) No PCN Allergy (N=103,164 hospitalizations) 30% 24% 25% 21% 21% 20% Internal Medicine17% 14% 15% 12% 13%

10% 6% 6% 5% Review 0% 0% Vancomycin Cipro Clindamycin Metronidazole Moxifloxacin

Macy E, Contreras R. J Allergy Clin Immunol, 2014. Outcomes: PCN Allergy Label

1. Higher rate of treatment failures 2. Increased prevalenceOHSU of Clostridium difficile, MRSA, and VRE 3.InternalIncreased future healthcare Medicine utilization 4. Increased healthcare dollars 5. Higher ratesReview of surgical site infections

Macy E, Contreras R. J Allergy Clin Immunol, 2014. Jeffres MD, et al. J Allergy Clin Immunol, 2016. Picard M, et al. J Allergy Clin Immunol Pract, 2013. Blumenthal KG, et al. Clin Infectious Dis, 2018. Surgical Site Infections

When controlled for surgery type, age, sex, race, American OHSU Society of Anesthesiologists class, procedure duration, and wound Internal Medicineclass

51% increased risk of a SSI in patients Review that have a PCN allergy label (p<0.04)

Blumenthal KG, et al. Clin Infectious Dis, 2018. Choosing Wisely Campaign (2014) OHSU Internal Medicine Review

https://www.choosingwisely.org Severe Cutaneous Adverse Reactions (SCAR) OHSU Internal Medicine

Shenoy ES, et al. JAMA, Review 2019. Stratifying Allergy Risk OHSU Internal Medicine Review

Shenoy ES, et al. JAMA, 2019. Stratifying Allergy Risk OHSU Internal Medicine Review

Shenoy ES, et al. JAMA, 2019. Stratifying Allergy Risk OHSU Internal Medicine Review

Shenoy ES, et al. JAMA, 2019. Penicillin Testing

• Modified protocol – Skin prick andOHSU intradermal testing • Penicilloyl-polylysine Internal• Penicillin G Medicine – Observed (graded) oral amoxicillin challenge • NPV of 97-100Review% – PPV not well https://www.medscape.com/viewarticle/871833 established Whose Responsibility OHSU Internal Medicine Review

Shenoy ES, et al. JAMA, 2019. Wallet Card for Patient

ALLERGY INFORMATION

Name: ______OHSU I am NOT Allergic to Penicillin Date of Birth: ______Penicillin Skin Testing (Prick and Intradermal) followed by an oral graded Amoxicillin Challenge was performed at Oregon Health and Science University (OHSU) on: Allergies: ______. ______Internal______MedicineRESULTS: Negative (No Reaction) ______Test performed by ______. ______Review Take Home Points

• 32 million patients have a PCN allergy label • >95% of themOHSU can actually tolerate penicillin • Patients with a PCN allergy label have poorer clinical outcomes and higher Internalhealthcare costs Medicine • Patients can be risk stratified based on clinical presentationReview • Patients should be evaluated as soon as possible Shenoy ES, et al. JAMA, 2019. Food Allergies OHSU Internal Medicine Review Food Allergy Epidemiology

• Potential life threatening condition – Affects 5-10%OHSU of the US population • Food Intolerance vs Food Allergy – 15-20% of adults report food intolerance Internal– Non-immunologic response Medicine • Sensitization vs Clinical Food Allergy – 20-40% areReview sensitized to at least 1 food – 5-8% likely have a true food allergy • 1 in 160 adults have a peanut allergy

Bird, et al. J Allergy Clin Immunol Pract, 2018. Current Treatment Strategies

• History/testing/challenge to confirm diagnosis OHSU • Education •InternalStrict avoidance of culpritMedicine food • Epinephrine autoinjector – AntihistaminesReview in certain situations Oral Peanut Immunotherapy (OIT) OHSU Internal Medicine Review

Bird, et al. J Allergy Clin Immunol Pract, 2018. Efficacy of Oral Immunotherapy OHSU Internal Medicine Review

Bird, et al. J Allergy Clin Immunol Pract, 2018. Adverse Events of OIT OHSU Internal Medicine Review

Bird, et al. J Allergy Clin Immunol Pract, 2018. Patch Immunotherapy OHSU Internal Medicine Review

Sampson HA, et al. JAMA, 2017. Take Home Points

• Differentiation between food allergies and tolerances should always be discussed with patients OHSU – Common intolerance symptoms include bloating, abdominal discomfort, diarrhea, “brain fog,” Internalheadaches, and fatigue Medicine • New therapies for food allergies will be available in the next 1-3 years – Oral food immunotherapyReview – Patch food immunotherapy Allergic Rhinitis OHSU Internal Medicine Review Key Questions

1. Is there benefit of using a combination of an oral antihistamine and an intranasal steroid (INS)OHSU compared to monotherapy? 2. How does montelukast compare with an Internalintranasal steroid? Medicine 3. Is there clinical benefit using combination therapy with an INS and an intranasal antihistamineReview compared with monotherapy? INS +/- Oral Antihistamine OHSU

•InternalNo change in mini-RQLQ, nasal Medicine inspiratory flow, nasal symptom score, nasal NO levels, conjunctivitis score, nasal/eye symptom- free days, headache symptom-free days, rescue medication need, or adverseReview events.

Dykewicz MS, et al. Ann Allergy Asthma Immunol, 2017, Montelukast? OHSU Internal Medicine Statistically significant clinical benefit of INS compared with montelukast. Also, addition of montelukast toReview INS does not produce clinically significant improvements over INS alone. ICS + Antihistamine Nasal Spray OHSU Internal Medicine Review Take Home Points

• Initial therapy for allergic rhinitis should be intranasal steroids • The addition ofOHSU oral antihistamines to intranasal steroids does not provide any clinically Internalsignificant benefit Medicine • Intranasal steroids are more effective than monotherapy with montelukast • The combinationReview of intranasal steroids and intranasal antihistamines is more effective than either as monotherapy Questions? OHSU Internal Medicine

Combined Clinic for ReviewSevere Sinus Disease ENT & Allergy