Extrapolating Evidence-Based Medicine of AIT Into Clinical Practice in the United States.

Allergy/immunology specialists in the United States prescribing allergy immunotherapy (AIT) have placed a heavy value on practical experience and anecdotal evidence rather than research-based evidence. With the extensive research on AIT conducted in the last few decades, the time has come to better implement evidence-based medicine (EBM) for AIT. The goal of this review was to critically assess EBM for debated concepts in US AIT practice for respiratory allergies in the context and quality of today's regulatory standards. Debated topics reviewed were the efficacy and safety of AIT in various subgroups (eg, polyallergic patients, older patients, patients with asthma, and pregnant women), diagnosis topics (eg, skin prick test vs allergen-specific serum IgE, factors affecting skin prick tests, use of nasal or conjunctival allergen challenges, and telemedicine for diagnosis), and dosing topics (eg, optimal dosing for subcutaneous immunotherapy and sublingual immunotherapy tablets, US liquid allergen extract history, duration of treatment, and biomarkers of efficacy). In addition, EBM for patient-centered AIT issues (eg, adherence, use of practice guidelines, and pharmacoeconomics) and the approach to implementation of AIT EBM in future clinical practice were addressed. The EBM for each concept was briefly summarized, and when possible, a practical, concise recommendation was given.

Evidence-based dosing of maintenance subcutaneous immunotherapy: a contemporary review of state-of-the-art practice.

BACKGROUND: Subcutaneous immunotherapy is an effective allergy treatment only if properly dosed. In this article we review the data on the probable effective dose range for subcutaneous immunotherapy and convert the recommended doses into a clinically relevant format. METHODS: A comprehensive literature search of dose-response subcutaneous immunotherapy studies was done of EBM databases, Medline database, PreMedline, and the National Guideline Clearinghouse for the period 1980-2016. Recommended doses were converted to the volume of allergen extract that should be added to a 5-mL maintenance vial. RESULTS: A safe and effective dose for subcutaneous immunotherapy is likely 5-20 µg of major allergen per injection. A 0.5-mL injection from a 5-mL maintenance vial containing 0.2 mL of manufacturer's extract of each allergen should reach the lower end of the probable effective dose range for most allergens. A larger volume of extract is required to reach that range when treatment includes cat, dog, or only 1 dust mite. Increasing beyond the commonly prescribed 0.2 mL of manufacturer's extract added to a 5-mL treatment vial is reasonable for nearly all allergens to achieve a maintenance dose higher in the probable effective dose range. CONCLUSION: Current otolaryngic allergy practice usually escalates patients to 0.5-mL injections from 5-mL maintenance vials containing 0.2 mL of manufacturer's extract of each allergen. With the main exceptions of cat and dog, those injections administered 1 or 2 times per month likely provide an efficacious dose of allergen and are consistent with published guidelines. A larger volume of extract should be considered in certain clinical situations.

Otoscopic signs of otitis media.

BACKGROUND: Lack of agreed-upon diagnostic criteria for acute otitis media (AOM) has led to inconsistencies in clinical care, misleading research results, and misguided educational efforts. The objective of this study was to examine findings that expert otoscopists use when diagnosing AOM. METHODS: A group of experienced otoscopists examined 783 children presenting for primary care. In addition, endoscopic still images of the tympanic membranes (TMs) were obtained. A random sample of 135 of these images was sent for review to a group of 7 independent physicians who were expert otoscopists. We examined the findings that both groups of observers used to distinguish between AOM, otitis media with effusion (OME), and no effusion. RESULTS: Among both groups of observers, bulging of the TM was the finding judged best to differentiate AOM from OME: 96% of ears and 93% of ear image evaluations assigned a diagnosis of AOM by members of the 2 groups were reported as showing bulging of the TM, compared with 0% and 3%, respectively, of ears and ear image evaluations assigned a diagnosis of OME. Opacification of the TM was the finding that best differentiated OME from no effusion. CONCLUSIONS: We describe findings that are used by experienced otoscopists to diagnose AOM and OME. The findings point to the advisability under most circumstances of restricting antimicrobial treatment for AOM to children who have TM bulging, and they call into question clinical trials of the treatment of AOM in which TM bulging has not been a required element for participation.