The American Academy of Allergy, Asthma & Immunology (AAAAI) released a list of “Five Things Physicians and Patients Should Question” as part of Choosing Wisely, an initiative of the ABIM Foundation. This list of evidence-based recommendations is designed to help patients and physicians start conversations and make wise choices regarding the diagnosis and treatment of allergy, asthma and immunologic diseases.
“As allergist/immunologists, we understand the importance of delivering the best care possible to millions of children and adults who suffer from allergies, asthma or immunologic disorders,” said AAAAI President Wesley Burks, MD, FAAAAI. “As internists or pediatricians with advanced training in allergy/immunology we also understand that symptoms of these chronic, often debilitating diseases can mirror other conditions. Appropriate, cost-effective care starts with an accurate diagnosis and a clear understanding of the severity of the condition.”
The AAAAI offers these five recommendations for diagnosing or treating adults:
Don’t perform unproven diagnostic tests such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests in the evaluation of allergy.
Specific IgG testing is not a test for an allergic condition. Skin and blood testing to foods has a high rate of showing positive results in people who don’t have food allergy; this also can be observed with skin testing to inhalants, but less frequently. For these reasons, appropriate diagnosis and treatment of allergy requires specific IgE (skin or blood) testing guided by the patient’s history and physical examination.
Don’t order sinus computed tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis.
Most cases of acute rhinosinusitis can be diagnosed without a sinus CT scan or other imaging studies. Antibiotics are not recommended for treating the majority of acute sinus infections. Viral infections cause most acute rhinosinusitis and only 0.5 percent to 2 percent progress to bacterial infections. Most acute rhinosinusitis resolves without treatment in two weeks. Antibiotics are not helpful in treating viral infections. In cases where treatment is required, amoxicillin should be the first-line antibiotic.
Don’t routinely do diagnostic testing in patients with chronic urticaria.
In the overwhelming majority of patients with chronic urticaria, a definite etiology is not identified. Limited laboratory testing may be warranted to exclude underlying causes. Targeted laboratory testing based on clinical suspicion is appropriate. Routine extensive testing is neither cost-effective nor associated with improved clinical outcomes. Skin or serum-specific IgE testing for inhalants or foods is not indicated, unless there is a clear history implicating an allergen as a provoking or perpetuating factor for urticaria.
Don’t recommend replacement immunoglobulin therapy for recurrent infections unless impaired antibody responses to vaccines are demonstrated.
Immunoglobulin replacement therapy, also known as IVIg or SCIg, can be a lifesaving form of treatment for many forms of primary immunodeficiency disease (PIDD). Most PIDD are inherited by genes that cause defects in the immune system. Immunoglobulin therapy replaces the antibodies that the immune system cannot produce due to the defect. This therapy is expensive and it does not improve outcomes for adults suffering from most recurrent infections. To determine if an adult’s immune system is able to produce antibodies, a physician can give the patient a vaccine meant to protect against conditions such as pneumonia. If the immune system is not impaired and produces antibodies against the vaccination, then immunoglobulin therapy is not needed nor recommended for treating this person’s recurrent infections.
Low levels of immunoglobulins (isotypes or subclasses), without impaired antigen-specific IgG antibody responses, do not indicate a need for immunoglobulin replacement therapy. Exceptions include IgG levels <150mg/dl and genetically defined/suspected disorders. Measurement of IgG subclasses is not routinely useful in determining the need for immunoglobulin therapy. Selective IgA deficiency is not an indication for administration of immunoglobulin.
Don’t diagnose or manage asthma without spirometry.
Too often, clinicians rely on symptoms when diagnosing and managing asthma, but these symptoms may be misleading. Spirometry is a breathing test that measures how well the lungs are working. Spirometry is essential to confirm the diagnosis of asthma and the severity of the disease in patients who can perform this breathing test. It also measures how well treatment is working in managing this life-long condition.
Recent guidelines highlight spirometry’s value in stratifying disease severity and monitoring control. Reliance on history and physical exam alone has been shown to under-estimate asthma control and over-estimate response to asthma treatment. When patients achieve and maintain control of asthma, they have fewer asthma flare-ups, their quality of life improves, and trips to urgent care centers or emergency rooms are reduced if not eliminated.
To learn more about Choosing Wisely, visit www.choosingwisely.org
