taining Allergy Education - Amazon S3 › clippingsme-assets › ... · • Allergic rhinitis...
Transcript of taining Allergy Education - Amazon S3 › clippingsme-assets › ... · • Allergic rhinitis...
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Clin
ic & P
rovid
er Trainin
g Packet
Allergy Education
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The mission of Wellspring Medical Services, regarding allergy treatment, is to assist and facilitate the development of an effective and profitable ancillary service in your practice.
Our Mission
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By the end of the course, participants will • Gain an understanding of allergies and how they are effecting
the medical condition of your patients • Understand proven solutions to test & treat patients who suffer
with allergic disease • Understand how an allergy program works • Understand patient safety during allergy testing & treatment • Understand how an allergy program can be successfully
implemented (Managers/Owners only)
Course Objectives
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What is an allergy?
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Schatz M, Allergy 2007: 62 (Suppl.85): 9-16
Survey of Allergic Rhinitis in USA
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Gaugris, et al. J Asthma 2006; 43: 1-7 Prieto JL Clin Exp Allergy 1996;26(1): 61-67 Meltzer EO Allergy Asthma Proc 2005;26:334-340
What percentage of the patients in your practice has allergic disease?
• Allergic rhinitis 15-40% of population • Asthma 7% of population
• 50-100% of patients with asthma have AR • 20-40% of patients with AR have Asthma
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Allergic Rhinitis: Specific Triggers • Pets: cats, dogs, rabbits, hamsters, horses, • Home or work/school: moisture problem,
poorly maintained A/C or indoor air turnover, cockroach exposure, carpets
• Symptoms worse in specific areas: garden, hobby, sport, smoky bars
• Non-allergenic irritants: fragrances, smoke, chemicals, change in temp/humidity
• Outdoor airborne: grasses, trees, weeds
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The relationship of allergies to other common conditions • Asthma • Sleep Disordered Breathing • Nasal Obstruction • Chronic Rhinosinusitis • Rashes, Hives, Eczema
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Allergies & Asthma
Mullarkey MF. J Allergy Clin Immunol . 1980;65:122-126. Smith JM. In: Middleton E, et al, eds. Allergy: Principles and Practice . 3rd ed. St. Louis, Mo: CV Mosby Company; 1988;2:891-929.
• Allergic rhinitis 15-40% of population • Asthma 7% of population • 50-100% of patients with asthma have AR • 20-40% of patients with AR have asthma
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Asthma Impact • 26 million asthmatics ( 8.6 million children) • > 20 million outpatient visits per year • > 1.8 million ED visits per year • > 500,000 hospitalizations per year • > 20 million lost work days per year • > 14 million lost school days per year • > 35 million prescriptions per year • Nearly 5000 deaths per year
Stelmach R, et al. CHEST 2005; 128:3140–3147 Malick A, Grant JA. Allergy. 52(34 Suppl):55-66, 1997. Niggemann, et al. Allergy 2006;61:855-859. F
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Allergy & Sleep Disorders Two Causes of Sleep Disturbance in AR
–Obstructive model • Nasal obstruction interferes with nasal breathing • – Arousals/awakenings 2º to obstruction
– Inflammatory dysregulation model • Inflammatory mediators disrupt sleep on a
central level
Craig et al., J Allergy Clin Immunol , 2005;116:1265 F
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Allergy & Mouth/Voice Problems • Mouth Breathing Inhalant allergies can affect voice by : • Excess secretions (PND, tracheal & • locally generated) • Direct local reaction (vocal fold
edema, as with Reinke’s) • Laryngeal drying from mouth
breathing
Corey J et al. Otolaryngol Clin N Am 1998;31:189-205 Jackson-Menaldi C, et al. Log Phon Vocol 2002;27:74-79
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Allergy & Sleep Disorders • Mechanical obstruction of the airway leads to
increased nasal airway resistance • Disruption in normal breathing leads to
awakenings and arousals • Many inflammatory mediators are involved in
the regulation of sleep • Histamine • Cysteinyl leukotrienes • Prostaglandins • Cytokines
Craig et al., J Allergy Clin Immunol , 2005;116:1265 F
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Allergy Symptoms: Skin • Dry, scaly skin, ranging from dandruff to
lichenification • Pruritis is characteristic (signs of scratching) • Varies from eczema, contact dermatitis &
urticaria to angioedema
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Allergy Treatment
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Immunotherapy Introduction • “We cannot control the effects of all stimulation
from our external environment. • Our body has the ability to inhibit the effects of
certain types of stimulation, if the stimulation schedule is regular, smooth, and without abrupt changes in stimulus intensity.
• Such is ...immunotherapy, where the body is regularly exposed to an antigenic stimulus.”
Haydon RC, Gordon B Aerollergen injection immunotherapy. In: Gordon B, Krouse J, Derebery J, Chadwick S, eds. Allergy and Immunology: An Otolaryngic Approach. Phil.: Lippincott Williams and Wilkins: 2001. F
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Early Days of Immunotherapy • Koessler (1914) demonstrated
tolerance to pollen challenge after immunotherapy
• Used a measurably safe, progressive, and reproducible escalation of doses
• The benefits of IT were shown to alleviate allergy symptoms, following one or two years of therapy
Koessler KK. The specific treatment of hayfever by active immunization. Illinois Med. J. , 1914; 25:120-127.
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Treatment Options for Allergy
Koessler KK. The specific treatment of hayfever by active immunization. Illinois Med. J. , 1914; 25:120-127.
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The Goal of Immunotherapy • The goal of immunotherapy is to escalate antigen dose to the point of highest tolerated dose • This dose should also control symptoms without causing unacceptable local or systemic reactions
Otolaryngol Head Neck Surg 1995; 113:597-602 F
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Efficacy of Immunotherapy Since 1954, 22 of the 26 best-designed, double-blinded clinical trials have shown efficacy: • 18/21 showed either
• Increased sp IgG • Decreased sp IgE, or both
• 9 studies that measured change in skin testing • 4 showed no change, • 5 demonstrated decreased skin reactivity
• 6/7 studies demonstrated • decreased nasal, or • conjunctival reactivity
Bierman, et al Allergy, Asthma, and Immunology from Infancy to Adulthood
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Efficacy of Immunotherapy in Asthma/Rhinitis: Meta-analysis • Assessed >40 controlled rhinitis studies from 1980 - 1998
• Significantly greater improvement in clinical symptoms in the active group in approximately 80% of studies
• Assessed >16 controlled asthma studies published since 1980
• Clinically relevant efficacy reported in 11/16 (69%)
Malling HJ. Immunotherapy as an effective tool in allergy treatment. Allergy. 1998;53:461-472.
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Development of Asthma in Patients with Allergic Rhinitis on IT
1 Lombardi C. Respir Med . 2001;95:9-12. 2 Jacobsen L. Allergy. 1997;52:914-920. 3 Valloviirrtta E.. J Investig Allergol Clin Immunol .. 1997;;7::369--370.. 4 Yang X.. Drugs.. 2001;;61::365--374 .. F
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Adding Allergy Program to your Practice
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Why Test for Allergies?
• Confirm the presumptive diagnosis of allergies • Identify specific allergens • Determine the level of the patient’s sensitivity • Correlate the findings with the clinical picture • Necessary when considering immunotherapy
Malling HJ. Immunotherapy as an effective tool in allergy treatment. Allergy. 1998;53:461-472.
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Scratch Test Based Immunotherapy • Commonly used for the diagnosis
of inhalant allergy and the provision of immunotherapy.
• With a vial test, immunotherapy based on prick testing alone can be safe and effective.
• If prick positive, start treatment as #6 endpoint. (c/w MQT approach).
Skin Testing for Inhalant Allergy: Current Strategies. AAOA Monograph; John H. Krouse, Richard L. Mabry, MD
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Treatment Board Preparation •Make up five-fold dilutions 1-6 •The treatment board diluent choice is usually phenolated saline (PNS)
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Allergy Coding & Reimbursement Challenges
• Not all carriers recognize all testing techniques • Some carrier policies restrict allergy testing • In 2008 many medical polices were revised to
include non-coverage of SLIT (not yet FDA approved)
• Most common payment denial – inadequate documentation!
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Typical Allergy Program Problems
• Some Patients will fail to understand immunotherapy or will get frustrated with slow results
• Some Patients will quit mid-treatment • Some Patients will fail to remain compliant to the
program • Some Patients will fail to understand costs/copays,
etc…
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Managing Allergy Risk
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Immunotherapy Risk
• Anaphylaxis is the most important risk in allergy immunotherapy
• Reactions occur in up to > 36% in rush and cluster protocols (which we do not do)
• Technique determines risk
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Immunotherapy Risk
• In 1994, U. S. Food and Drug Administration estimated U.S. death rate from immunotherapy to be 0.7 deaths per million injections (0.00007%)
Turkeltaub PC. Deaths associated with allergenic extracts. FDA Med Bull 1994; May:7
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Immunotherapy Risk Study
Hurst DS, Gordon BR, Fornadley JA, Hunsaker DH. Safety of Home Based and Office Allergy Immunotherapy: a multicenter prospective study. Otolaryngol Head Neck Surg 1999; 121:553-561
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Study Design
• Prospective 12 month study • SCIT • 27 U.S. medical offices • AAOA Fellows, in practice for 5 - 15 years • 635,600 visits and 1,144,000 injections
Hurst DS, Gordon BR, Fornadley JA, Hunsaker DH. Safety of Home Based and Office Allergy Immunotherapy: a multicenter prospective study. Otolaryngol Head Neck Surg 1999; 121:553-561
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Study Goals
• Determine the degree of safety • Compare safety of home and office treatment • Identify all risk factors
Hurst DS, Gordon BR, Fornadley JA, Hunsaker DH. Safety of Home Based and Office Allergy Immunotherapy: a multicenter prospective study. Otolaryngol Head Neck Surg 1999; 121:553-561
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Systemic Reactions
Hurst DS, Gordon BR, Fornadley JA, Hunsaker DH. Safety of Home Based and Office Allergy Immunotherapy: a multicenter prospective study. Otolaryngol Head Neck Surg 1999; 121:553-561
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Risk Management • Risk Factor for Major Reaction: Active Asthma
• Moral: ask each patient about their condition before each injection. • Risk Factor for Major Reaction: New Vial - First Shot
• Moral: Use a vial test when beginning a new vial. • Risk Factor for Major Reaction: Errors
• Moral: Use a vial test when beginning a new vial & give careful dose instructions for home injections.
• Risk Factor for Major Reaction: Beta Blocker treatment • Some experienced allergy providers do cautiously treat these patients
Hurst DS, Gordon BR, Fornadley JA, Hunsaker DH. Safety of Home Based and Office Allergy Immunotherapy: a multicenter prospective study. Otolaryngol Head Neck Surg 1999; 121:553-561 L
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Treatment for Anaphylaxis • We will call provider for help • Tourniquet above & lidocaine with epinephrine at injection site • Patient supine or in Trendelenburg • Administer epinephrine (Provider) • ABCs, prepare for airway management • Prepare Oxygen for Administration • Give bronchodilator inhalers • Give H1 & H2 antihistamines, steroids, heparin as needed (Provider) • Establish IV; start rapid infusion (Provider)
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Conclusion • Allergic Rhinitis is common. • Allergic Rhinitis affects Asthma, some skin diseases and other symptoms. • Allergies are treatable. • Immunotherapy in the only treatment that improves the patient’s own
immune response. • Immunotherapy has been demonstrated to be both effective and safe. • Immunotherapy will improve the health of many patients. • Immunotherapy can safely and profitably be incorporated into your practice.
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Making Your Allergy Program Work
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Making Your Allergy Program Work
– The secret to making an allergy program successful is to agree upon a simple and repeatable patient flow process.
– Once this process has been established, communicating any necessary changes to keep the program working correctly
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Allergy Program Success Key #1
– Include an allergy “page” in your new-patient forms.
– Review: Chart Update Form – Give these forms to us and we will verify, call
and schedule.
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Allergy Program Success Key #2
– When taking patient vitals & reviewing medical history MA asks,
“Do you have allergies such as; hay fever, rashes, stuffy nose, or sinus problems?”
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Allergy Program Success Key #3
– MA makes a quick note on the chart (A+ or A-).
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Allergy Program Success Key #4
– Provider asks: “I see you are suffering with allergies. Could you please tell me about that?”
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Allergy Program Success Key #5
– Provider walks the patient down the hall to the allergy testing room.
– Or… give a copy of the A+ (patients with allergies) charts to us and we will verify, call & schedule