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American Academy of Otolaryngic Allergy | Clinical Care Statements | January 2015 T www.aaoaf.org most recent medicalliterature indecidingthebestcoursefortreating theirpatients. constantly occurinmedicine, andsomeadvanceswilldoubtless occurfasterthanthese Statementscanbeupdated.Otolaryngicallergists willwant tokeepabreast ofthe for oragainstaparticularcompany’s products. TheStatementsare notmeantforpatientstouseintreating themselves ormakingdecisionsabouttheircare. Advances and practicesfrom current medicalliterature. Theydonotattempttodefineaqualityofcare forlegalmalpracticeproceedings. Theyshouldnotbetakenas recommending Note: AmericanAcademyofOtolaryngicAllergy’s (AAOA)Clinical Care Statementsattempt toassistotolaryngicallergists bysharing summariesofrecommended therapies , andfamotidine. skin reactionsforuptotwodaysandincludecimetidine, H2 blockers havethepotentialtosuppresshistamine shown toinhibitskintesting. lorazepam, andmidazolam. before thetestingandincludeclonazepam,diazepam, shouldbediscontinuedfor7days response from7to14daysdependinguponthetype. antidepressantscansuppresstheantihistamine to threeweeks. have beenshowntostopthehistamineresponseforup response. Topical glucocorticosteroidscanblockthehistamine day, onthesuppression ofimmediateskintests. dose steroids,i.e.greaterthan20mgofprednisoneper orrelativelyhigh- opinion abouttheeffectsoflong-term do notsuppressskintesting. oralcorticosteroids(30mgdailyforaweek) Short-term testing forupto48hours. () nasalsprayhasbeenshowntosuppress for avariablelengthoftime,upto7days.Astelin Second-generation antihistaminesalsosuppresstesting have activehistaminesuppressionforupto11days. several typesincludingCyproheptadine(Periactin) can canbestoppedfor72hours,however, a variableperiodoftime.Ingeneral,first-generation Antihistamines suppressthehistamineresponsefor medicinediscontinuation. without unnecessary counseling, thegoalistoyieldinterpretableskinresults withallergytesting.Withcould interfere properpatient thorough understandingoftheclassesmedicinesthat negative histaminecontrol.Providers shouldhavea known todecreaseoreliminateskinreactivity, causinga should avoidpriortoskintesting.Thesemedicinesare 11, 12,13 in determining whichmedicinespatients in determining care statementtoassisthealthcareproviders Allergy (AAOA) hasdevelopedthisclinical he AmericanAcademy ofOtolaryngic | [email protected] 14 Applicationofpotenttopicalsteroids 1, 2,3,4,5,6,7 18, 19 15 8 Alprazolamhasalsobeen Thereisadifferenceof 17 | 202.955.5010 | 11130 Sunrise 9, 10 Medicines to Avoid Before 15, 16 Valley Drive, proceeding withdiagnosticskintesting. provider haveapositiveskinhistamineresponsebefore response.Therefore,itisimperativethatthe couldsuppressthe er thecombinationofthesedrugs herbal agentsthatalonehaveaminoreffect,wheth unclear, ifapatientistakingmultiplepharmaceutical/ agentforashorttime.Itis taking onepharmaceutical many ofthesestudiesaredonewhenthepatientis Healthcare providersshouldtake intoconsiderationthat single–dose crossoverstudy, itwasfeltthatcommon testing. Inthemostcomprehensivestudy, Herbal productshavethepotentialtoaffectskinprick tacrolimus Pimecrolimus Topical calcineurininhibitorshaveavariableaffect. suppress skinreactivityforuptosixmonths. Treatment withomalizumab(anti-IgEantibody)can skin testing. blockers arelativecontraindicationtoinhalant treatment resistantanaphylaxis,makingtheuseofbeta Beta blockers areariskfactorformoreseriousand ACE inhibitorsdidnotaffecthistamineskinresponse. Cyclosporin didnotaffectskinhistamineresponse. to bediscontinued. and proteinpumpinhibitors(PPIs)arefeltnottoneed Selective norepinephrinereuptake inhibitors(SNRIs) affect skintesting. Selective serotoninreuptake inhibitors(SSRIs)donot testing. receptorantagonistdidnotaffectskin medicine. ayurvedic cellulose powder, traditionalChinesemedicine,Indian unshiupowder,nettle, citrus lycopuslucidus,spirulina, histamine response medicinesdosometimeshaveasignificant alternative skin response.However, andother complementary herbal productsdidnotsignificantlyaffectthehistamine Allergy Skin TestingAllergy 25, 26,27 Suite100, 12 did. 22 didnotaffecthistaminetestingbut Reston, 15, 28 15 24 andincludedbutterbur, stinging

VA 20191 23 usinga 20, 21 - 29 30 American Academy of Otolaryngic Allergy | Clinical Care Statements | January 2015 11 Int Arch Ann Allergy J Allergy Clin The diagnosis Journal of www.aaoaf.org February 2009; February

Allergy | J Allergy Clin Immunol Ranitidine (150 mg daily) Allergy 2003; Effect of topical pimecrolimus Int Arch Allergy Immunol Suppression of the early and late Role of on skin prick test. Cyclosporin A in atopic dermatitis: skin tests and free IgE levels [email protected]

The effects of on the | J Allergy Clin Immunol 2004; 114:695. Immunological and clinical changes in allergic Successful treatment of chronic drug-resistant urticaria Successful treatment of chronic The effects of on intradermal wheal and 202.955.5010

Journal of Allergy and Clinical Immunology 2009; Journal of Allergy and Clinical | Practical guide to skin prick testing in allergy to Practical guide to skin prick testing Journal of Allergy and Clinical Immunology Herbal supplements and skin testing. Predicting which medicine classes interfere with allergy skin Predicting which medicine classes Allergy 2012; 67:18-24. Suppression of immediate skin tests by ranitidine. Allergy and Asthma Proceedings 2010; 31:477-482. Allergy and Asthma Proceedings 20191 VA Otolaryngology Head and Neck Surgery 2003; 129(3):199-203.

during reduction and cessation of omalizumab therapy. on epicutaneous skin testing. cutaneous allergic responses using and montelukast. Asthma Immunol 2001; 86:44. Allergol Immunopathol (Madr) 2001; 29:66. diseases. results of skin prick tests used in the diagnosis of allergic Allergy Immunol 2011; 154:63. therapeutic response is dissociated from effects on allergic reactions. Br J Dermatol 1991; 124:43. Asthma and American College of Allergy, Asthma and Immunology, and Immunology. Asthma Joint Council of Allergy, Immunology, and management of anaphylaxis: an updated practice parameter. Immunol 2005; 115:S483. inhibits wheal, flare, and itching reactions in skin-prick tests. inhibits wheal, flare, and itching Proc 2007; 28:711. Allergy and Clinical Immunology 1989; 84:895-899. asthmatics following treatment with omalizumab. Spergel JM, Nurse N., Taylor P., PameixSpake A. PameixSpake P., Spergel JM, Nurse N., Taylor et al. More, D.R., et al. Mainardi, T. Hill, S.L., Krouse, J.H. Simons FE, Johnston L., Gu X., Simons KJ. Cudhadaroglu C., Erelel M., Kiyan E., et al. Isik SR, Celikel S., Karakaya G., et al. Munro CS, Higgins EM, Marks JM, et al. American Academy of Allergy, on Practice Parameters, Force Joint Task Shah, K.M. et al. et al. Bousquet, J. Duenas-Laita, A. et al. I., Bochenska-Marciniak M., et al. M., Kuprys Kupczyk et al. J. Miller, G. Hanf G., Kunkel Noga O., et al. Shapiro G., Reimann J., Corren J.,

121:506. 2008; 22 23 58:492-494. 24 123(2). 25 flare. 26 27 28 29 30 15 testing. 16 aeroallergens. 17 alprazolam. without 123:504-505. 18 19 20 131:46. 2003; 21 Reston, Journal Suite 100, Skin test . J Allergy A comparison of Duration of the inhibitory Drive, Valley Long-term oral corticosteroid Pediatr Dermatol 2008; 25:26 Pediatr Histamine skin test reactivity Prolonged treatment with topical Sunrise 11130 Journal of Allergy and Clinical Immunology 1974; Suppressive effects of topical furoate Clinical pharmacology of new International Journal of Dermatology 2005; Inhibition of the dermal immediate allergic reaction Ann Allergy Asthma Immunol. 2003; 91:258-62. (1b). Journal of Allergy and Clinical Immunology 1990; A controlled study of the effects of corticosteroids on Allergy Diagnostic Testing: an updated practice parameter. Allergy Diagnostic Testing: Effective topical corticosteroid application frequency and Skin reactivity to codeine and histamine during prolonged Allergy. 1988; 43:593-6 (111). Allergy. Clin Pharmacokinet. 1999; 15:277-86. (11a).

and tacrolimus on skin prick testing in children. glucocorticoids results in an inhibition of the allergen-induced wheal-and-flare response and a reduction in skin mast cell numbers and histamine content. Clin Esp Allergy 1989; 19:19. histamine induced wheals. through prolonged treatment with topical glucocorticosteroids Clin Immunol 1987;79:345. following single and multiple doses of azelastine in patients with following single and multiple doses of azelastine nasal spray seasonal allergic . immediate skin test reactivity. prick tests. therapy does not alter the results of immediate skin allergy of Allergy and Clinical Immunology 1996; 98(3):522-7. cromoglycate on histamine and allergen induced weals in human skin. cromoglycate on histamine and allergen induced weals in Br J Clin Pharmacol. 1983; 15:277-86. (11a). Almind, M., Dirksen, A., UG. Nielsen, NH., Svendsen, activity on histamine-induced skin weals of sedative and non-sedative EO. Meltzer, DS., Grossman, J., Pearlman, suppression by antihistamines and the development of subsensitivity. suppression by antihistamines Immunology 1985; 76:113-7 (111). Journal of Allergy and Clinical controlled study with five antihistamines. antihistamines: a double blind Immunology 1973; 51:7107. (111). Journal of Allergy and Clinical and sodium the in vivo effects of , , chlorpheniramine Annals of Allergy and Asthma Immunology 2008; 100:S18. Annals of Allergy and Asthma Narasimha, S.K., Andersson M., Pipkorn U. Andersson M., Pipkorn U. OD. Wolthers Gradman J., Hammarlund A., Enerback L.Pipkorn U. Slottri, Zweiman B. et al. L.,Des Roches, A., Bougeard, Y.H. Paradis, Olson, R. et al. Simons, FE., Simons, KJ., Simons, FE., Simons, KJ., Cook, TJ., MacQueen, DM., Wittig, HJ., Thornby, JI., Lantos, RL, JI., Virtue, CM. Thornby, MacQueen, DM., Wittig, HJ., Cook, TJ., suppression and side effects with Degree and duration of skin test I., Davies, RJ. Meyrick Thomas, RH., Moodley, Phillips, MJ., Bernstein, L. et al Leavengood, DC., Nelson, HS. CJ., Wagner, RJ., Taylor, Long, WF.,

1 2 most recent medical literature in deciding the best course for treating their patients. in deciding the best course for treating medical literature most recent Note: American Academy of Otolaryngic Allergy’s (AAOA) Clinical Care Statements attempt to assist otolaryngic allergists by sharing summaries of recommended therapies by sharing summaries of recommended Statements attempt to assist otolaryngic allergists (AAOA) Clinical Care Note: American Academy of Otolaryngic Allergy’s recommending They should not be taken as for legal malpractice proceedings. They do not attempt to define a quality of care medical literature. current and practices from Advances themselves or making decisions about their care. not meant for patients to use in treating The Statements are products. for or against a particular company’s of the will want to keep abreast allergists constantly occur in medicine, and some advances will doubtless occur faster than these Statements can be updated. Otolaryngic 14 44(5):425-427. 13 11 12 10 therapy. corticosteroid 86:153-159. 54:229-235. 9 8 antihistamines. 6 antagonists. 7 5 4 3

Medicines to Avoid Before Avoid to Medicines Allergy Testing Skin 20191 VA

Reston, Suite 100, Drive, Valley Sunrise 11130 | 202.955.5010 | [email protected] | www.aaoaf.org 12

American Academy of Otolaryngic Allergy | Clinical Care Statements | January 2015 www.aaoaf.org most recent medicalliterature indecidingthebestcoursefortreating theirpatients. constantly occurinmedicine, andsomeadvanceswilldoubtless occurfasterthanthese Statementscanbeupdated.Otolaryngicallergists willwant tokeepabreast ofthe for oragainstaparticularcompany’s products. TheStatementsare notmeantforpatientstouseintreating themselves ormakingdecisionsabouttheircare. Advances and practicesfrom current medicalliterature. Theydonotattempttodefineaqualityofcare forlegalmalpracticeproceedings. Theyshouldnotbetakenas recommending Note: AmericanAcademyofOtolaryngicAllergy’s (AAOA)Clinical Care Statementsattempt toassistotolaryngicallergists bysharing summariesofrecommended therapies

Immunosuppressant First GenerationAntihistamines MEDICATIONS ReuptakeSerotonin Inhibitors (SNRIs) Protein Pump Inhibitors(PPIs) ReuptakeNorepinephrine Inhibitors(SNRIs) Sprays Nasal Steroid (ACE)Angiotensin-Converting Inhibitors Topical Corticosteroids Histamine2 Antihistamines(H2Blocker) Tricyclic andTranquilizers Antidepressants EyeDrops Antihistamine NasalSprays Second GenerationAntihistamaines Suppressant Effects of Drugs onImmediateSkinTests*Suppressant EffectsofDrugs | [email protected] Medications thatDONOTNeedtobeStopped Prior toAllergy SkinPrickTesting* | 202.955.5010 *See priorreferences 1 2 | 11130 Sunrise Medicines to Avoid Before 1 Someexceptionsseepriorreferences Valley Drive, SUPPRESSED MEAN DAYS 0 0 0 2 Allergy Skin TestingAllergy

Suite100, Beclomethasone Dipropionate Nasal Beclomethasone Dipropionate Mometasone Furoate Nasal Furoate Nasal Acetonide Reston, Nasal Nasal Esomeprazole Lansoprazole Escitalopram Pantoprazole Rabeprazole Omeprazole Cyclosporin Venlafaxine Citalopram Perindopril Duloxetine Benazepril Paroxetine Quinapril Lisinopril Sertraline Enalapril Ramipril

VA 20191 SUPPRESSED MAX DAYS Up to21 14 2 1 1 7 5