Services

Select ServicesFood Allergy Reaction HotlineAllergy ShotsClinical ResearchCluster ImmunotherapyDrug AllergyEnvironmentalFood AllergyFood Allergy Risk Reduction (FARR®)Food Oral Immunotherapy (OIT)Insect AllergyMedicationsMetal AllergyPulmonary Function TestsSkin TestingXolair

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  Allergy Shots

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  Allergy shots (also called subcutaneous immunotherapy, or SCIT) is one of the best treatments available for your allergies and asthma. It is one of the few disease-modifying therapies available in medicine and targets the underlying cause of various allergic conditions. SCIT offers the potential of improving asthma control, providing relief from allergy and sinus symptoms, and reducing the need for medicines in the future. In children, allergy shots are particularly helpful as they can reduce the risk of becoming more allergic or developing asthma later in life.

  WHAT ARE ALLERGY SHOTS?

  Allergy shots contain all-natural proteins from allergens found in the environment. Patients are first tested to determine what they are allergic to. Customized allergen extract vials are then produced for each patient based on these results which are injected underneath the skin.

  HOW DO ALLERGY SHOTS WORK?

  By giving increasing doses of allergen proteins in the body, our immune system starts to recognize and become tolerant to these substances. Once tolerance is achieved with a SCIT regimen, we don’t experience allergic inflammatory reactions when exposed to allergens in the environment. Ultimately, this leads to improved symptoms and less reliance on medications. Studies have shown a sustained effect of symptom relief for many years after the completion of a SCIT regimen.

  WHAT’S INVOLVED IN ALLERGY SHOTS?

  Regimens for allergy shots include two phases, the build-up phase and the maintenance phase. Allergy injection build-up is the process of gradual dose increases working up to the target or therapeutic dose. This allows the body time to get used to receiving something it is allergic to. Once the target dose has been achieved, this dose is maintained for a period of 3-5 years in most patients. It is during this maintenance phase that the immune system becomes tolerant and shifts from being allergic to becoming non-allergic. Although allergy shots are not a cure for allergies, it acts on the immune system to prevent the allergic response from even starting, as opposed to just treating symptoms once they occur. Each patient is different and both build-up and maintenance can be customized to meet individual needs.

  WHAT ARE THE RISKS OF ALLERGY SHOTS?

  Most reactions to shots are localized and appear as redness or swelling at the injection site. This typically occurs within a couple of hours of the injection and clears up soon afterwards. Systemic reactions are much less common and can range in severity. Most reactions are mild and include symptoms such as itching, sneezing, congestion, or hives. Rarely, a more serious systemic reaction (or anaphylaxis) can occur that may lead to coughing, wheezing, swelling of the throat, or dizziness. Most systemic reactions occur within the first 30 minutes of the injection, which is why it is important that injections are only administered in a medical facility where patients can be observed during this time.

  WHAT ARE THE BENEFITS OF ALLERGY SHOTS WITH ALLERGY PARTNERS?

  Allergy Partners is the nation’s largest Allergy and Immunology practice, which has allowed us to compile the largest database of SCIT patients in the world. We have worked closely with leading allergen extract manufacturers and the national guideline committee for immunotherapy to develop our state of the art immunotherapy program. At Allergy Partners, we strive to provide the safest and most effective care for our patients.

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  Clinical Research

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  Want to be on the leading edge of therapeutic programs and diagnostic tests for allergies or immunodeficiency? Select Allergy Partners’ locations offer patients that opportunity through our clinical research studies. Our practice has been selected as one of the few in the nation to conduct FDA approved clinical research studies in our field.

  What are the benefits?

  One immediate benefit is that you are treated in the study at no financial cost to you and without the need of insurance. In addition, if you qualify for the clinical study and decide to participate, you are compensated for your time and travel.

  Why do we offer these research opportunities to patients?

  The clinical studies are in line with our mission to empower patients through education and research. These studies test safety and effectiveness of the latest pharmaceutical agents before and after these new medications reach the general public. Allergy Partners conducts FDA approved clinical research studies from Phases I to IV . These investigative studies are planned for improved treatment of asthma, allergic rhinitis, atopic dermatitis, immunodeficiency and other related problems.

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  Cluster Immunotherapy

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  What is Cluster Immunotherapy?

  Cluster immunotherapy is an accelerated version of traditional immunotherapy. Allergy Partners’ standard immunotherapy build up schedule calls for 26 incremental doses given once or twice a week. In Cluster, this build up period is condensed into 9 ‘sessions’ held once or, ideally, twice a week.

  Why Choose Cluster Immunotherapy?

  At each session, the patient will receive 1-3 doses of immunotherapy separated by a 30 minute waiting period. While sessions may last up to 90 minutes, a patient can reach maintenance dosages in a little as 4 weeks. Such a schedule may be very appealing to patients desiring to see results quicker or whose schedule is better suited to a more intensive initial phase of immunotherapy.

  What are the Risks?

  With such rapid escalation in dosing, there can be an increase rate of local reactions. There is also an increased risk of anaphylaxis. Allergy Partners recommends pre-medication with a non-sedating antihistamine and a leukotriene modifier for patients undergoing cluster.

  Cluster may not be suited for extremely sensitive patients or those with significant asthma or underlying medical conditions. Some providers may choose a slightly modified schedule based on your history, symptoms, and test results. As always, your Allergy Partners’ physician will discuss the relative risks and merits of Cluster with you to ensure that you receive immunotherapy in the manner best suited to your individual situation.

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  Drug Allergy

  Testing & Treatment

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  If you develop a rash, hives or difficulty breathing after taking certain medications, you may have a drug allergy. As with other allergic reactions, these symptoms can occur when your body’s immune system becomes sensitized to a substance in the medication, perceives it as a foreign invader and releases chemicals to defend against it.

  Symptoms

  While you may not experience allergic symptoms the first time you take a drug, your body could be producing antibodies to it. As a result, the next time you take the drug, your immune system may see it as an invader, and you’ll develop symptoms as your body releases chemicals to defend against it.

  These symptoms may include:

  • Skin rash or hives
  • Itching
  • Wheezing or other breathing problems
  • Swelling
  • Vomiting
  • Feeling dizzy or light-headed

  Anaphylaxis, a potentially life-threatening reaction that can impair breathing and send the body into shock; reactions may simultaneously affect two or more organ systems (for example, when there is both a rash and difficulty breathing)

  Penicillin causes most allergic drug symptoms. Just because you show allergic symptoms after taking penicillin doesn’t mean that you will react to related drugs, such as amoxicillin, but it’s more likely. Also, just because you had a reaction to penicillin (or any other drug) at one time doesn’t mean you will have the same reaction in the future.

  Antibiotics that contain sulfa drugs, such as Septra, Bactrim, and Pediazole, occasionally cause allergic reactions. Non-antibiotic drugs containing sulfa are very low-risk.

  Diagnosing

  Drug allergies can be hard to diagnose. An allergy to penicillin-type drugs is the only one that can be definitively diagnosed through a skin test. Some allergic reactions to drugs particularly rashes, hives and asthma can resemble certain diseases.

  Your allergist will also want to know whether you have had a reaction to any other drug. If you can, bring the suspected drug with you. This will help the allergist recommend alternatives as needed.

  Depending on the drug suspected of causing the reaction, your allergist may suggest a skin test.

  If a drug allergy is suspected, your allergist may also recommend an oral drug challenge, in which you will be supervised by medical staff as you take the drug suspected of triggering a reaction. (If your reaction was severe, a drug challenge may be considered too dangerous.)

  Management and Treatment

  If you have a drug allergy:

  • Make sure all of your doctors are aware of your allergy and the symptoms you experienced.
  • Ask about related drugs that you should avoid.
  • Ask about alternatives to the drug that caused your allergic reaction.
  • Wear an emergency medical alert bracelet or necklace that identifies your allergy.

  Anaphylaxis

  Anaphylaxis is a severe, potentially life-threatening reaction that can simultaneously affect two or more organ systems (for instance, when there is both swelling and difficulty breathing, or vomiting and hives). If this occurs, call 911 and seek emergency medical care immediately.

  If you are caring for someone who appears to be having a severe reaction to a drug, tell the emergency care team what drug was taken, when it was taken and what the dosage was.

  If your allergic reaction to a drug is not life-threatening, your allergist may give you:

  • An antihistamine to counteract the allergic reaction
  • A non-steroidal anti-inflammatory drug, such as ibuprofen or aspirin, or a corticosteroid to reduce inflammation

  Drug desensitization

  If there is no suitable alternative to the antibiotic that you are allergic to, you will need to undergo drug desensitization. This involves taking the drug in increasing amounts until you can tolerate the needed dose with minimal side effects. This will most likely be done in a hospital so immediate medical care is available if problems develop.

  Desensitization can help only if you are taking the drug every day. Once you stop it — for example, when a chemotherapy cycle ends — you will need to go through desensitization a second time if you need the drug again.

  Penicillin Allergy

  Nearly everyone knows someone who says they are allergic to penicillin. Up to 10 percent of people report being allergic to this widely used class of antibiotic, making it the most commonly reported drug allergy. Over time, however, the vast majority of people who once had a severe allergic reaction to penicillin loses sensitivity and can be treated safely with the drug (although 10 percent of individuals will remain allergic).

  Penicillin Allergy Testing and Diagnosis

  An allergist can help you evaluate the safety of taking penicillin.

  In addition to assessing your detailed history about a prior allergic reaction to penicillin, allergists administer skin tests to determine if a person is or remains allergic to the medication. These tests, which are conducted in our office, typically take about two to three hours, including the time needed after testing to watch for reactions.

  When safely and properly administered, skin tests involve pricking the skin, injecting a weakened form of the drug, and observing the patients reaction. People who pass penicillin skin tests by reacting negatively to the injection are seen as at low risk for an immediate acute reaction to the medication. The allergist might then give these individuals a single, full-strength oral dose to confirm the absence of a penicillin allergy.

  Those with positive allergy skin tests should avoid penicillin and be treated with a different antibiotic. If penicillin is recommended, people in some cases can undergo penicillin desensitization to enable them to receive the medication in a controlled manner under the care of an allergist.

  Penicillin Allergy Treatment

  Those who have severe reactions to penicillin should seek emergency care, which may include an epinephrine injection and treatment to maintain blood pressure and normal breathing.

  Individuals who have milder reactions and suspect that an allergy to penicillin is the cause may be treated with antihistamines or, in some cases, oral or injected corticosteroids, depending on the reaction.

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  Environmental

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  Our homes, schools and workplaces contain causes of environmental allergies. These inhaled “causes” can include: dust, animal dander, feathers, mildew and mold spores.

  The best defense is to avoid the allergens that cause your symptoms. This is not always easy to do, especially if the problem is plant pollens, mold, or other substances in the air that are difficult to avoid. Your allergist can provide information that will help decrease your exposure and discuss treatment options that will help reduce your sensitivity to those allergens that affect you.

  Useful tips for the most common environmental triggers:

  Dust mites are tiny bugs that live in bedding, mattresses, upholstered furniture, and carpets. No matter how clean your house is, it’s impossible to completely get rid of dust mites. However, you can limit contact, especially in the bedroom, if you:

  • Put special dust-proof covers on pillows, mattresses and box springs. Remove and clean the covers frequently.
  • Limit the number of stuffed animals kept in bedrooms or put them in plastic containers.

  Grasses, trees and weeds produce pollens that travel through the air and are inhaled. They cause seasonal allergy symptoms and trigger asthma. Pollens from trees are higher in the spring, grasses in the summer and weeds in the fall. The beginning and end of each season may vary depending on weather conditions and where you live. If possible:

  • Keep windows closed during pollen season, especially during the day.
  • Stay inside during mid-day and afternoon hours when pollen counts are highest.
  • Take a shower, wash your hair, and change clothing after working or playing outdoors.
  • Allergic reactions to pets are caused by the animal’s dander. Short-haired pets are not any less likely to cause a reaction than long-haired animals.
  • Keep the pet outdoors or restrict it to a few rooms in the house. At the very least, keep the pet out of the bedroom.
  • Wash hands after petting.
  • Bathe your pet once a week to reduce dander.

  Molds are found in outdoor air and can enter your home any time you open a door or window. Any house can develop a mold problem with the right conditions. Molds like to grow on wallboard, wood, or fabrics, but they will grow any place. They thrive in damp basements and closets, bathrooms (especially showers), places where fresh food is stored, refrigerator drip trays, house plants, air conditioners, humidifiers, garbage pails, mattresses, and upholstered furniture.

  You can control mold in your home if you:

  • Clean bathrooms, kitchens, and basements regularly and keep them well aired.
  • Do not use humidifiers.

  Other irritants that may also trigger your symptoms:

  • Smoke – Avoid tobacco smoke and do not allow anyone to smoke in your home or car. If you smoke, try to quit. Do not use wood burning stoves or fireplaces.
  • Odors – Stay away from strong odors such as perfume, hair spray, paint, cooking exhaust, cleaning products and insecticides. Room air fresheners and electronic air cleaners also can trigger symptoms.
  • Cold air – Cover your nose and mouth with a scarf.
  • Colds and infections – Wash hands frequently.
  • Exhaust – If you have an attached garage, don’t start the car and let it run in there. Fumes can make their way into the home even when the garage door is open.
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  Food Allergy Reaction Hotline

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  The COVID-19 pandemic has accelerated a change in the approach to food allergy reactions that has been discussed by allergists for the past several years.

  Epinephrine injection is the treatment of choice for anaphylaxis, the most severe form of a food allergy reaction. Patients and parents have been taught to use their epinephrine auto-injector (AUVI-Q, Epi-pen and others) when two body systems are involved in a reaction (e.g. rash [hives] and vomiting) or if there are significant respiratory symptoms (e.g., cough, wheeze, shortness of breath or change in the sound of the voice). Using epinephrine early in a reaction can prevent progression to more severe symptoms and saves lives. Because food allergy reactions are unpredictable and may progress despite a dose of epinephrine, however, the standard recommendation has been to go to the Emergency Department for evaluation and monitoring after every epinephrine use.

  Despite the safety of epinephrine auto-injectors (AUVI-Q, EpiPen and others), parents and patients have often been reluctant to use these devices. Numerous studies have shown that epinephrine has been used as little as 50% of the times when it should have been. In addition to fear of side effects and fear of needles, many patients and parents have wanted to avoid the inconvenience and cost of an Emergency Department visit. This reluctance to use the Emergency Department has been made worse by the fear of being exposed to coronavirus.

  Recently, food allergy experts from Food Allergy Research and Education and two highly regarded food allergy centers proposed a plan for the home management of anaphylaxis. The plan provides guidance on how to deal with food allergy reactions, including the use of epinephrine, at home. The doctors at Allergy Partners of North Texas believe that recommended approach is useful, however, we are concerned that the recommendations place too great a burden for medical judgment on the shoulders of patients and parents.

  Although we at Allergy Partners of North Texas have worked hard to support our patients 24 hours a day through our answering service, sometimes the service is too busy to answer immediately and sometimes, frankly, they make mistakes. Because after hours communications have not been 100% reliable, we have taught the standard recommendation that following epinephrine use, everyone should go to the Emergency Department.

  In an effort to provide the very best care for our patients, the doctors at Allergy Partners of North Texas have changed our recommendation to go to the Emergency Department after epinephrine use. Effective June 15, 2020, Allergy Partners of North Texas will institute a Food Allergy Emergency Hotline, (972) 566-8626, that will be answered 24/7/365 by an Allergy Partners of North Texas physician or physician’s assistant experienced in the management of food allergy reactions. This number should be called if there is a food allergy reaction involving the use of epinephrine. Patients should not delay the use of epinephrine by calling this number. The number should not be used for mild food allergy related problems or other management questions. Please see the graphic Food Allergy Action Plan below. Contact your Allergy Partners of North Texas physician through the Patient Portal if you have questions.

  

   

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  Food Allergy

  Testing & Treatment

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  Food allergies are due to an immune system reaction that occurs soon after eating a certain food. They affect about one in twenty Americans, with cases occurring at any age, but most commonly in babies and young children. While any food may cause an allergic reaction, eight types of food account for about 90 percent of food allergies: milk, egg, soy, wheat, peanuts, tree nuts, shellfish and fish.

  Symptoms

  Symptoms of a food allergy vary significantly from person to person, as does the amount of food needed to trigger an allergic reaction. While most food-related symptoms occur within two hours of ingestion, in some rare cases, the reaction may be delayed by four to six hours or even longer. Common symptoms of a food-related allergic reaction include: digestive problems, hives or swollen airways. The most severe allergic reactions may result in anaphylaxis, which can impair breathing, cause a dramatic drop in blood pressure, and affect heart rate to a fatal degree.

  Some patients may experience an itching and/or tingling feeling in their mouths after consuming certain fruits, which is referred to as pollen-food allergy syndrome or oral allergy syndrome. For example, patients allergic to birch pollen can have this reaction when eating an apple. In rare cases, pollen-food allergy syndrome can lead to anaphylaxis.

  Diagnosis

  The diagnosis of a food allergy generally requires a thorough medical history of the patient including what and how much you ate, how long it took for symptoms to develop, what symptoms you experienced and how long it lasted. Your doctor may order skin and/or blood tests in making a diagnosis. However, a “positive” result on any one test is not an absolute indication of a food allergy. Allergists rely on their experience to properly interpret the results of tests within the overall context of the patient’s medical history and properly diagnose a food allergy. If you suspect you have a food allergy, talk to your Allergy Partners physician to determine what method of diagnosis is most suitable.

  Skin Test

  In this test, a tiny amount of liquid containing suspected food is placed on the skin of your arms or back. The skin is then pricked with a small sterile probe, allowing the liquid to seep under the skin. After about 20 minutes, a hive (a bump similar to a mosquito bite) may form and will be compared to the bump at the site of the control, where a liquid not containing any allergen is placed.

  Blood Test

  A blood test (commonly known as RAST or ImmunoCAP) detects the presence of allergen-specific antibodies known as immunoglobulin E (IgE) antibodies.Additionally, a relatively new test, called a “component test” can be ordered to gain more specific information and is mostly used for peanut allergies. Blood tests have been used extensively but often are not specifically based on patients’ detailed diet diary. When not properly utilized, the results of a blood test can be very confusing and may lead to unnecessary food restriction. Allergy Partners allergists use their experience to determine when a blood test may be helpful and to properly interpret the results of the blood test.

  Other Tests

  There are a number of non-standardized tests that are advertised as helping diagnose food allergy. These tests include allergen-specific IgG blood tests, antigen leukocyte cellular antibody tests, hair analysis, and applied kinesiology. Their use in the diagnosis of food allergy is not advised.

  Oral Food Challenge

  In an oral food challenge, small increment amounts of food are fed to the patient over a period of a few hours to determine if a reaction occurs. Due to the possibility of a severe reaction, it must be conducted under medical supervision by an experienced doctor and in a facility with emergency medication and equipment on hand. The gold standard for a food challenge is one that is double-blind and placebo-controlled, though it may still have very good diagnostic value when lacking these conditions.

  Conclusion

  Food allergies can be challenging and stressful, so knowing what you or your child is eating is an important first step. If you have doubts about a possible food allergy, err on the side of caution until you have a chance to speak with an Allergy Partners physician.

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  Food Allergy Risk Reduction (FARR®)

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  Food allergy has become a significant worldwide concern. A food allergy occurs when the immune system mistakenly responds to food as if it was harmful and produces an antibody response, namely IgE. When a food allergen enters the body, it cross-links to IgE bound to special immune cells called mast cells. The mast cells then ‘pop’ and release chemicals such as histamine and tryptase. These chemicals, in turn, cause the classic symptoms of food allergy such as hives, swelling, cough, wheeze and anaphylaxis, in some instances.

  What is FARR®?

  Peanut allergy is an increasingly common and potentially life-threatening condition. Two recent studies indicate that, contrary to previous recommendations, the early introduction of peanut to the diet of at risk children lowers the risk of developing peanut allergy.

  These studies have profound clinical implications in that they offer a strategy to prevent the onset of peanut allergy in high-risk children. Recently, the National Institutes of Allergy and Infectious Disease (NIAID) convened an expert panel to review and revise guidelines for the introduction of peanut into the diets of infants. These new guidelines were published in January, 2017 and can be found at: www.jacionline.org/article/S0091-6749(16)31222-2/fulltext.

  • In summary, the new guidelines emphasize the following:
  • Consider peanut introduction into the diet between 4 and 6 months of age.
  • Risk factors including the presence and severity of eczema as well as the presence of any other food allergy should be taken into account in order to help determine the safest way to introduce peanut.

  These guidelines mark a significant change in the approach to food allergy, with an emphasis on prevention. Yet, there are several outstanding questions that remain, including how to approach children with other food allergies or children with food allergic first degree relatives.

  Given these considerations, Allergy Partners is pleased to offer the Food Allergy Risk Reduction (FARR®) Program. Developed by Richard Wasserman, MD, PhD of Allergy Partners of North Texas, FARR® is aimed at selected infants less than one year of age who might be at increased risk for allergy to foods such as milk, egg, or peanut. The children are skin tested to that food, and, if skin testing is negative or mildly positive, then challenged with the food (milk, egg or peanut). If there is no reaction, the parents are instructed to administer the specified quantity of food at least three times a week.

  Who should be referred for FARR®?

  The LEAP study only enrolled infants who had severe eczema or egg allergy. Such children are those most likely to benefit from FARR®. We know, however, that many children with food allergy do not meet those criteria. In an effort to assist you in counseling parents about the LEAP study and FARR®, we recommend referral of children with the following: Recommendations of the NIAID Expert Panel

  Recommendations of the NIAID Expert Panel

  • Severe eczema, egg allergy, or both

  While these patients are the most likely to develop peanut allergy, prior studies have identified other risk factors for peanut allergy which may increase the risk of at-home introduction of peanut for infants. Infants with the following risk factors for peanut allergy may also benefit from referral for the FARR® Program.

  • Moderate to Severe Eczema
  • Other food allergies
  • 2 or more first degree family members with significant allergic disease
  • Sibling or parent with peanut allergy
  • Sibling or parent with a food allergy other than peanut

  FARR® is not necessary for an infant already eating the food of concern without any adverse reactions. FARR® would rarely be appropriate for a child with no personal or family history of atopy. Children with a strongly positive in vitro (ImmunoCAP) food allergy test are not good candidates for FARR®.

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  Food Oral Immunotherapy (OIT)

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  Allergy Partners is excited to offer oral immunotherapy (OIT) for children with food allergies. Allergy Partners’ OIT program is an innovative program developed originally by Richard Wasserman, MD, PhD at Allergy Partners of North Texas.

  Allergy Partners is one of the first allergy practices in the country offering this breakthrough OIT program for kids with food allergies. The treatment provides an active intervention for patients with specific food allergies. It takes several months, and at the end of the program, most patients with allergies are able to consume these foods with no allergic reaction.

  More than 80% of patients treated with OIT by an Allergy Partners’ physicians can now safely consume foods that once threatened their health.

  Our OIT program has helped many patients and families dealing with food allergy. The treatment is a gradual desensitization process which works by introducing minute doses of specific food proteins and slowly increasing this dose over several months. As a result, the vast majority of our patients are able to consume these foods without adverse reactions. The Impact of Food Oral Immunotherapy Experience demonstrates that the program has dramatically changed the lives of families by helping their children eat foods that were previously harmful. The impact on family life has benefited not only the allergic child, but also their siblings and parents.

  What to expect from the Allergy Partners OIT Program

  This program is designed for a child of school age or older who is able to understand the reasons for participating and be actively engaged in the process.

  Once enrolled, the program will require an initial appointment and regular follow up visits. Initially, the child will receive multiple small doses of food, increasing at established time intervals over a set period of time. Our goal is that once oral immunotherapy is complete, the previously allergenic food may be freely included in the diet. The food MUST be eaten daily to maintain the ability to eat it safely. This treatment is not a cure but an active intervention that can lead to regular ingestion of the food without reaction.

  Want to know more about treating your child’s food allergy?

  If you are interested in learning more about Allergy Partners’ OIT Program please contact our office and discover how we can help children live without a fear of food.

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  Insect Allergy

  Testing & Treatment

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  Stinging Insect Allergy Testing and Desensitization

  Severe stinging insect allergy affects over 9.5 million Americans including 3% of adults and up to 1% of children. There are 40-100 deaths in the US per year and that number has not changed in the past 30 years. An adult who has experienced anaphylaxis with a sting has a 60-70% chance of having a similar or more severe reaction with the next. Fortunately, venom immunotherapy is 95-98% effective in preventing such reactions and can be lifesaving therapy.

  Stinging Insects

  Stinging insects belong to the order Hymenoptera which include the family Apidae ( Honeybee, Sweatbee, and Bumblebee), the family Vespidae (Yellow Jackets, Yellow Hornets, White-faced Hornets, and Paper Wasps), and the family Formicida (the Fire Ant and Harvester Ant).

  Yellow jackets are the most frequent culprits in North America except along the Gulf coast where wasps are more common. Yellow jackets are scavengers and seek food at picnics and in trashcans, orchards, and dumpsters. They are highly aggressive and sting for no apparent reason especially in autumn while competing for limited food supplies. They tend to nest in the ground or in cracks in buildings or landscaping materials. Hornets are aerial nesters, often building in trees and bushes, and are sensitive to vibration and noise like lawn mowers.

  Paper wasps are found in the eaves or windows of houses and around decks. They have a narrow waist but can be a multitude of colors including black, brown, red, or striped. The Mediterranean wasp is now in the US and has black and yellow stripes, which commonly lead to it being mistaken for a yellow jacket.

  Honeybees are usually docile except for the Africanized hybrids which tend to swarm and be more aggressive. The venom, however, is the same. Most honeybee stings are seen in bee keepers or people who play outdoors without shoes or garden without gloves.

  Fire ants have a true sting apparatus but will bite to anchor to the skin and then pivot to deliver multiple stings. They entered the US through the Gulf in the 1940s but have been found as far north as Maryland. The sting results in a characteristic sterile pustule. In endemic areas like the Florida Gulf, over half of the population is stung every year.

  Reactions

  Sting reactions are classified as local or systemic, and the previous reaction history is the best determinate of future reactions. Prior history of other atopic disease and family history of bee sting allergy do not increase a person’s risk for anaphylaxis.

  Most local reactions are a late-phase IgE dependent reaction that is mild and develops 12-24 hours after the sting. They can be impressive and worrisome with the amount of swelling and can involve an entire limb. Lymphangitic, red streaks can occur. They usually resolve within 5-10 days and are not dangerous except for potential physical compression of the head, neck, tongue, or throat If stung in those areas. These reactions are usually treated with ice, pain control, and antihistamine but early use of steroids within the first hours after a sting can be helpful, especially to stings around the face, head, and neck. Infection is unusual in sting reactions except with yellow jackets. Lymphangitis that develops after 24-48 hours is usually related to the allergic process and not infection.

  Systemic reactions are almost all IgE mediated and cause anaphylaxis. Signs and symptoms of anaphylaxis may affect the skin (hives, angioedema, flushing, itching), the respiratory system (cough, wheeze, stridor, etc.), the circulatory system (dizziness, hypotension, loss of consciousness, etc.) and the GI tract (cramps, diarrhea, nausea, vomiting). The absence of skin symptoms is associated with more severe reactions. Systemic reactions may also be caused by underlying mast cell disorders in 1-2% of cases.

  Evaluation

  Clinical history is the best determinate of risk for future reactions and in deciding who would benefit from testing and therapy. One in five healthy adults has detectable IgE to venom, so testing people without a significant history of anaphylaxis is not recommended. Testing and, if testing is positive, immunotherapy is recommended for: (1)Any adult with more that local reaction including systemic cutaneous (skin) symptoms like hives, and (2) Any child with systemic symptoms not limited to skin only such as respiratory, cardiac, GI, etc. The following table shows relative risk of systemic reaction based on age and previous reaction. Children with only cutaneous symptoms only like hives are at no higher risk than anyone with a large local reaction and shots are not recommended.

  

  Testing is done with an intradermal method skin test with or without blood testing for specific IgE. Skin testing is usually positive for patients with a good history but can be negative especially in the first 4-6 weeks due to a refractory period of anergy. If skin testing is negative, often serum testing is performed, as 10% of patients with a negative skin test will have a positive serum specific IgE. If both are negative, skin testing is often repeated in 3-6 months and a serum tryptase should be checked to screen for mast cell disorders. Why not just do serum testing? Up to 20% of patients with a positive skin test and good history of anaphylaxis will have negative serum testing. Skin testing, therefore, is the initial test of choice in people who have had allergic reactions to stings.

  Treatment

  Treatment of large local reactions, especially around the head and neck, are often treated with a short burst of oral corticosteroid over 5 days. For adults with systemic symptoms and children with systemic symptoms other than skin only should be evaluated for immunotherapy. Venom immunotherapy (VIT) can be 95-100% effective in preventing future reactions to stings and have no higher incidence of adverse reactions than inhalant allergen immunotherapy regardless of the type of schedule is used to build up on therapy. VIT is usually given 1-2 times per week. Bee venom immunotherapy is usually built up over 17 injections and fire ants take longer at 28 or more injections. At Allergy Partners, we prefer a cluster build up which builds up more rapidly providing protection sooner. This involves 1-3 injections in 8 sessions over 4 weeks. Once at full maintenance dose, shots are continued monthly for 12-18 months and then every 4-6 weeks.

  Another concern in patients with anaphylaxis of any kind is the possible interference of other medications. Beta blockers are blood pressure medications that can increase risk for anaphylaxis by interfering with the effects of epinephrine. Selective beta 1 blockers have not been determined to have the same risk yet. Risk analysis shows that stopping Beta blockers in cardiovascular patients creates higher risk than not stopping them during VIT. The question of ACE inhibitors and the increase in risk for anaphylaxis has been less clear with studies showing increase and others showing no correlation with risk of anaphylaxis with their use. It is therefore important for venom allergic patients to review all of their medications with their Allergy Partners physician and notify him or her when any changes have been made.

  Summary

  The risk of repeat severe reactions to stinging insects can accurately be predicted and venom immunotherapy can be lifesaving for these individuals. Given the high risk of repeated severe reactions, adults with any systemic reaction other than localized should be assessed by an allergist and given the option of VIT. Children are at slightly lower risk but should also be evaluated for any reaction that is systemic and not isolated to the skin alone. Venom immunotherapy can lower risk from as high as 70% for future reactions to 2-5%.

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  Medications

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  Allergy Medication

  When you cannot avoid allergens, there are many medications that can help control allergy symptoms. Decongestants and antihistamines are the most common allergy medications. They help to reduce a stuffy nose, runny nose, sneezing and itching. Other medications work by preventing the release of the chemicals that cause allergic reactions. Nasal corticosteroids are effective in treating inflammation in your nose.

  An allergist will work with you to determine which medicines are best for you and how often and how much of them you should take — while eliminating or minimizing any side effects.

  Asthma Medication

  There are many effective medicines to treat asthma. Most people with asthma need two kinds — Quick-relief medicines — taken at the first sign of any asthma symptoms for immediate relief:

  • Short-acting inhaled beta2-agonists
  • Anticholinergics

  Your doctor also may recommend you use these medicines before exercise for treatment of asthma. Quick-relief medicines can stop asthma symptoms, but they do not control airway inflammation that causes the symptoms. If you find that you need your quick-relief medicine to treat asthma symptoms more than twice a week, or two or more nights a month, then your asthma is not well controlled. Be sure to tell you doctor.

  Long-term control medicines — taken every day to prevent symptoms and attacks:

  • Antileukotrienes or leukotriene modifiers
  • Cromolyn sodium and nedocromil
  • Inhaled corticosteroids
  • Long-acting inhaled beta2-agonists (never taken alone)
  • Methylxanthines
  • Oral corticosteroids
  • Immunomodulators

  These medicines are taken every day even if you do not have symptoms. The most effective long-term control medicines reduce airway inflammation and help improve asthma control.

  Your doctor will work with you to find the right medicine, or combination of medicines, to manage your asthma, and will adjust the type and amount based on your symptoms and control. The goal of asthma treatment is to have you feel your best with the least amount of medicine.

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  Metal Allergy

  Testing & Treatment

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  The evaluation and treatment of systemic and cutaneous hypersensitivity reactions of a person to implanted metals can be a bit challenging. Current recommendations suggest that metal hypersensitivity testing can be of great help in the case of patients who were previously suffering from metal hypersensitivity, like nickel.

  Also, testing for metal hypersensitivity can help in pre-operative evaluation of those patients suffering from conditions like multiple drug allergies, autoimmunity (SLE and RA), eczema, fibromyalgia or chemical hypersensitivity. It can also be helpful in those patients who have had a failure of an orthopedic implant.

  Allergy Partners offers full panel testing for bone cement and metal allergy. Testing is carried out in our offices and requires three office visits over 4-5 days. The test involves placing patches across your back with the use of hypoallergenic tape. We will then apply an allergen paste on an area of your skin that is free from rashes. As the test site is read at varying intervals, if a rash similar to that of eczema develops, it can indicate that you have sensitivity to a certain metal.

  After the testing, your results will be given to you and your referring doctor. You as well as your referring doctor can use these results for making a suitable decision for the procedure that you will undergo according to your test results and medical history.

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  Pulmonary Function Tests

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  Lung function tests (also called pulmonary function tests, or PFTs) check how well your lungs work. The tests determine how much air your lungs can hold, how quickly you can move air in and out of your lungs, and how well your lungs put oxygen into and remove carbon dioxide from your blood.

  Spirometry is the first and most commonly performed lung function test. It measures how much and how quickly you can move air out of your lungs. For this test, you breathe into a mouthpiece attached to a recording device (spirometer). The information collected by the spirometer may be printed out on a chart called a spirogram.

  Common lung function values measured with spirometry:

  • Forced vital capacity (FVC). This measures the amount of air you can exhale with force after you inhale as deeply as possible.
  • Forced expiratory volume (FEV). This measures the amount of air you can exhale with force in one breath. The amount of air you exhale may be measured at 1 second (FEV1), 2 seconds (FEV2), or 3 seconds (FEV3). FEV1 divided by FVC can also be determined.
  • Forced expiratory flow 25% to 75%. This measures the air flow halfway through an exhale.
  • Peak expiratory flow (PEF). This measures how much air you can exhale when you try your hardest. It is usually measured at the same time as your forced vital capacity (FVC).
  • Maximum voluntary ventilation (MVV). This measures the greatest amount of air you can breathe in and out during 1 minute.
  • Slow vital capacity (SVC). This measures the amount of air you can slowly exhale after you inhale as deeply as possible.
  • Total lung capacity (TLC). This measures the amount of air in your lungs after you inhale as deeply as possible.
  • Functional residual capacity (FRC). This measures the amount of air in your lungs at the end of a normal exhaled breath.
  • Residual volume (RV). This measures the amount of air in your lungs after you have exhaled completely. It can be done by breathing in helium or nitrogen gas and seeing how much is exhaled.
  • Expiratory reserve volume (ERV). This measures the difference between the amount of air in your lungs after a normal exhale (FRC) and the amount after you exhale with force (RV).
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  Skin Testing

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  What is Allergy Testing?

  When you are allergic, your body is reacting to a particular substance that should not normally bother you. These substances are called allergens. Typical allergens include pollens, dust mites, animal dander, foods, insect stings and even medicines. To determine which substances are triggering your symptoms, your allergist/immunologist will test your skin using tiny amounts of commonly troublesome allergens.

  Allergy testing is generally very safe and effective. Under the guidance of a trained Allergist-Immunologist, allergen skin test is considered the Gold Standard for the diagnosis of allergy.

  Who Should be Tested for Allergies?

  People of all ages with symptoms that suggest they have allergic disease can be tested. These symptoms include:

  Respiratory symptoms: Nasal congestion, runny nose, cough, wheezing, watery eyes, itchy eyes, nose, throat

  Skin symptoms: Eczema, hives, itchiness

  Abdominal symptoms: Abdominal pain and diarrhea after eating certain foods

  Severe life threatening reactions, or anaphylaxis: This typically occurs with ingestions of foods or medication or insect stings (i.e. bees, wasps, fire ants)

  Why is Allergy Testing Important?

  Allergy testing is vital in identifying which substances are causing your allergies, allowing you and your Allergy Partners allergist/immunologist to more effectively manage your symptoms.

  Treatment options can range anywhere from allergen avoidance (i.e. minimizing dust exposure) to allergen immunotherapy (i.e. allergy shots). Allergen immunotherapy helps your body to develop immunity or tolerance to allergens.

  What Types of Allergy Tests are Available?

  There are a few different types of allergy tests. These are the most common:

  Prick technique: A small amount of allergen is introduced into the skin by making a small puncture with a plastic applicator through a drop of the allergen extract.

  Intradermal technique: This test involves injecting a small amount of allergen under the skin with a very small syringe. This form of testing is done if the skin prick tests are negative.

  Blood (Immunocap) tests: This test involves drawing blood to determine if you have allergic, or IgE, antibodies. This type of test is usually only performed if you cannot stop medications that interfere with skin tests, or if you have a diffuse rash, such as eczema or psoriasis.

  The allergen extracts are manufactured commercially and are standardized according to the U.S. Food and Drug Administration (FDA) requirements.

  As with any medical test, the results should be interpreted carefully and be coupled with a person’s history and physical exam. Allergy Partners allergists/immunologists are uniquely trained experts in the interpretation of allergy tests.

  What Will Happen During Allergy Testing?

  During your test, allergic antibodies will activate skin cells, called mast cells. Mast cells release chemicals, such as histamine, that cause swelling and redness, only in the areas where the allergens have touched your skin. This process usually only takes 15 minutes. The hives usually resolve within 30 minutes to one hour.

  Is There Anything I Should Do Prior to Testing?

  There are some medications, such as antihistamines, that interfere with allergy testing. Your doctor will ask you to stop these medications for several days prior to testing. If you are unsure if a medication will interact with the test, you should contact your Allergy Partners physician for guidance.

  Is There Anything I Should Refrain From Doing after Testing?

  There are no real limitations to one’s activity after testing. However, if you take a sedating antihistamine, such as diphenhydramine, you should avoid drinking alcohol or driving, as recommended on the bottle.

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  Xolair

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  Xolair is an antibody that helps decrease allergic responses in the body. Xolair is used to treat moderate to severe asthma that is caused by allergies in adults and children who are at least 12 years old. It is not a rescue medicine for treating an asthma attack.

  It is also used to treat chronic hives in adults and children who are at least 12 years old.

  Xolair is usually given after other medicines have been tried without success.