Physician Misunderstandings About Allergies Unsafe

Laird Harrison

March 06, 2014

SAN DIEGO — Many physicians mistakenly believe that people with egg allergies should avoid measles, mumps, influenza, and rabies vaccines cultured in egg. It's a popular misconception — one of many about allergies that is harming patients and costing money, according to experts from the American Academy of Allergy, Asthma & Immunology (AAAAI).

"Most flu vaccines are actually grown in an egg culture so there has always been a concern that people with an egg allergy who get the vaccines will have a reaction," said Theodore Freeman, MD, an allergist in private practice in San Antonio, Texas. In fact, "this doesn't happen."

Dr. Freeman was part of a committee of experts working on a list of 5 don'ts of allergy treatment and testing, which was released here at the AAAAI 2014 meeting.

The list is part of the Choosing Wisely campaign, developed by the American Board of Internal Medicine Foundation to improve efficiency in the American healthcare system. Dozens of professional organizations have released similar lists.

The AAAAI initiative now consists of 10 don'ts; the first 5 waste-busting recommendations were released in 2012.

The new list states that no special precautions are needed for egg-allergic patients receiving mumps, measles, or rabies vaccines. For an egg-based influenza vaccine, patients should be observed for 30 minutes after the injection or given an egg-free vaccine.

"Much of the care delivered in America is unnecessary," said AAAAI president Linda Cox, MD, a private-practice allergist in Fort Lauderdale, Florida, who presented the new list.

"Each of these don'ts has the potential to have a huge impact on our patients and on our resources," said Dr. Freeman. "All of these items fall in our purview, and they're all evidence-based."

Table: The 5 Don'ts on the 2014 AAAAI Choosing Wisely List

Don't routinely avoid influenza vaccination in egg-allergic patients.

Don't perform food immunoglobulin (Ig)E testing without a history consistent with potential IgE-mediated food allergy.

Don't routinely order low- or iso-osmolar radiocontrast media or pretreat patients who have a history of seafood allergy with corticosteroids and antihistamines.

Don't overuse non-beta lactam antibiotics in patients with a history of penicillin allergy; appropriate evaluation is required before such use.

Don't rely on antihistamines as first-line treatment for severe allergic reactions.

The experts acknowledge that they cannot show that the 2012 list has resulted in healthcare savings or changed the way physicians are practicing — an aspect of the plan that has been criticized.

They note that they are not aware of any attempt to document the impact of such lists. "The purpose is not necessarily to track costs, but to spark conversation," said David Lang, MD, professor of medicine at the Cleveland Clinic, and a member of the list committee.

"It's really about starting a conversation between patients and physicians," Dr. Cox explained. "It helps me to have a piece of paper for patients to review and digest. It gives them a little more comfort that this is coming from an organization that gave this some thought."

Dr. Freeman has disclosed no relevant financial relationships. Dr. Cox reports that she has served on advisory boards of Stallergenes and Medimmune, and as a consultant to Circassia, Novartis, and Biomay. Dr. Lang reports that he has served as a consultant to Hycor, GlaxoSmithKline, and Quest.

American Academy of Allergy, Asthma & Immunology (AAAAI) 2014. Presented February 28, 2014.