Allergy and Asthma - Practical Diagnosis and Management.pdf (8,623 KB)

Allergy and Asthma - Practical Diagnosis and Management.pdf (8,623 KB)  

Contents
Authors . . .  . . . . . . . . . . . . xvii
Preface . . .  . . . . . . . . . . . . xxii
1. Introduction to the Immune System .. 1
Massoud Mahmoudi, DO, PhD
The Immune System 1 Cells of the Immune System 7
Innate Immunity 1 Mast cells 7 Natural Killer Cells 1 Basophils 8
Complement System 2 Eosinophils 8
Adaptive Immunity 2 Defective Immune System 8
Humoral Immunity 2 Hypersensitivity Diseases 8
Cell-Mediated Immunity 2 Type I: Immediate Hypersensitivity or Anaphylactic 8
Interaction of Antigen and Antibody 4 Type II: Antibody-Mediated Hypersensitivity 8
B Cells: Responsible for the Production of Antibodies 4 Type III: Immune Complex–Mediated Hypersensitivity 10
Autoimmunity 4 Type IV: Cell-Mediated Hypersensitivity 11
T Cell–Antigen Interaction 6 Evidence-Based Medicine 11
T Helper Cell Regulation 6 Bibliography 11
2. The History and Physical Examination of the Allergic Patient . . . . . . . . . 12
Mary Alice Murphy, MD, MPH
The Physical Examination 12 The Physical Examination of the Allergic Patient 14
The Medical History 12 Vital Signs 14
Chief Complaint 12 General Appearance 15
Review of Systems 12 Skin 15
Medications 13 Face 15
Drug Allergies 13 HEENT: Head, Eyes, Ears, Nose, and Throat 15
Current Medications 13 Neck 15
Past Medications 13 Chest 16
Hospitalizations 13 Cardiovascular 16
The Clinic or Large Health Maintenance Additional Examination (as Indicated
Organization Settings 13 by the Patient Complaint) 16
Occupational History 13 Procedures 16
Social History 13 Skin Testing 16
Environmental Exposures 14 Spirometry and Peak Flow Meters 16
Personal Habits 14 Pulse Oximetry 16
Dietary (Food) History 14 Nitrous Oxide Measurement 17
Geographic History 14 Endoscopy 17
Family History 14 Evidence-Based Medicine 17
Previous Allergy Diagnosis and Conclusion 17
Treatments 14 Bibliography 17
3. Prevalence of Allergic Diseases in Children, Adults, and the Elderly . .. . 18
Massoud Mahmoudi, DO, PhD
Allergic Rhinitis 18 Occupational Allergy 20
Respiratory Allergy-Allergic Asthma 18 Evidence-Based Medicine 20
Food Allergy 19 Bibliography 20
Atopic Dermatitis 20


4. Allergic Diseases of the Eye . . . . . . . . . . . . . . . . 21
Eric Kavosh, MD and Leonard Bielory, MD
The Ocular Surface 21 Contact Dermatitis of the Eyelids 27
Clinical Examination 21 Blepharoconjunctivitis 27
Immunopathophysiology of Ocular Allergy 22 Ocular Allergy Treatment 27
Acute Allergic Conjunctivitis 24 Vasomotor Conjunctivitis or Perennial Chronic
Vernal Keratoconjunctivitis 25 Conjunctivitis 30
Atopic Keratoconjunctivitis 25 Conclusion 30
Giant Papillary Conjunctivitis 26 Evidence-Based Medicine 30
Dry-eye Syndrome (Tear Film Dysfunction) 26 Bibliography 31
5. Prevalence of Pollens in the United States and Elsewhere . . . . . 32
Jennifer Yoo, MD and Massoud Mahmoudi, DO, PhD
Tree Pollen 32 Africa 33
Grass Pollen 32 Asia 33
Weed Pollen 32 Europe 36
Methods of Pollen Collection 33 Evidence-Based Medicine 36
Worldwide Prevalence of Pollens 33 Bibliography 37
North America 33
6. Allergic Rhinitis: Diagnosis and Treatment . . . . . . . . . . . 38
Dennis K. Ledford, MD
Pathophysiology and Specific IgE 38 Rhinitis Associated with Systemic Diseases
Epidemiology 40 or Anatomic Defects 46
Classification of Allergic Rhinitis 41 Treatment of Allergic Rhinitis 48
Differential Diagnosis of Allergic Rhinitis 41 Allergen Avoidance 48
Allergic Rhinitis 41 Allergen Immunotherapy 48
Perennial Nonallergic Rhinitis 43 Pharmacotherapy 51
Nonallergic Rhinitis with Eosinophilia 45 Future Therapeutic Options for Allergic Rhinitis 52
Rhinitis Induced by Drugs or Hormones Conclusion 53
(Rhinitis Medicamentosa) 46 Evidence-Based Medicine 53
Atrophic Rhinitis 46 Bibliography 53
7. The Effect of Rhinitis on Sleep, Quality of Life, Daytime Somnolence, and Fatigue . . . . . . . 55
Carah Santos, MS and Timothy J. Craig, DO
Evidence for Sleep Impairment in Allergic Rhinitis 55 Effects of therapy 60
Mechanisms of Sleep Impairment 56 The Role of Intranasal Corticosteroids 60
Nasal Congestion 56 Conclusion 60
Immune Response Mediators 58 Evidence-Based Medicine 60
Sleep Impairment and Quality of Life 58 Bibliography 61
The Effects of Sleep Impairment 58
Measuring Sleep Impairment and Impact
on Quality of Life 59
8. Sinusitis . . . . . . . . . . . . 62
Kevin C. Welch, MD and Andrew N. Goldberg, MD, MSCE, FACS
General Considerations 62 Bacteriology 66
Classification of Rhinosinusitis 62 Acute Bacterial Rhinosinusitis 67
Anatomy 62 Chronic Rhinosinusitis 67
The Septum and Turbinates 62 Diagnosis 68
The Ostiomeatal Complex 63 History and Physical Examination 68
The Paranasal Sinuses 63 Diagnostic Imaging 69
Pathophysiology 65 Culture 69
Acute Bacterial Rhinosinusitis 65 Treatment 69
Chronic Rhinosinusitis 66 Medical Therapy 69
Antibiotic Therapy 69 Fungal Rhinosinusitis 72
Surgical Therapy 71 Allergic Fungal Sinusitis 72
Complications 71 Invasive Fungal Sinusitis 72
Orbital Complications 71 Evidence-Based Medicine 72
Intracranial Complications 72 Conclusion 73
Bibliography 73
9. Allergic Diseases of the Ear . . . . . . . . . . .. . . . . . 74
Doris Lin, MD and Steven W. Cheung, MD
General Considerations 74 Otitis Media with Effusion 76
Allergic Diseases of the External Ear 74 Food Allergy in Otitis Media with Effusion 76
Chronic Otitis Externa 74 Allergic Diseases of the Inner Ear 77
Contact Sensitivity 74 Ménière’s Disease 77
Dermatophytid Reaction 74 Evidence-Based Medicine 77
Allergic Diseases of the Middle Ear 74 Bibliography 77
Eustachian Tube Dysfunction 75
10. Cough and Allergic Diseases . . . . . . . . .. . . . . . . . 78
Eric M. Chen, MD, FACP, FAAAAI, FACAAI
Definition and Physiology 78 Asthma and Cough 80
Causes of Cough 78 Cough Variant Asthma 81
Upper Airway Cough Syndrome Nonasthmatic Eosinophilic Bronchitis 81
(Postnasal Drip Cough) 78 Gastroesophageal Reflux Disease and Cough 81
Allergic Rhinitis and Cough 78 Symptomatic Treatment of Cough 81
Nonallergic Rhinitis and Cough 79 Conclusion 83
Infectious Rhinitis and Cough 80 Evidence-Based Medicine 83
Angiotensin-Converting Enzyme Inhibitor Cough 80 Bibliography 83
11. Urticaria and Angioedema . . . . . . . . . . .. . . . . . . . . . 84
Bettina Wedi, MD, PhD and Alexander Kapp, MD, PhD
Classification of Urticaria 84 Special Types of Urticaria 91
Spontaneous Urticaria 84 Cholinergic Urticaria 91
Acute Urticaria 84 Aquagenic Urticaria 91
Chronic Urticaria 85 Contact Urticaria 91
Physical Urticaria 88 Angioedema Without Urticaria 92
Dermographic Urticaria 88 Classification of Angioedema Without Urticaria 92
Delayed Pressure Urticaria 89 Non–C1 INH Deficient Angioedema Without Urticaria 92
Cold Urticaria 89 Hereditary Angioedema 93
Localized Heat Urticaria 90 Acquired C1 INH Deficiency Angioedema 93
Solar Urticaria 90 Evidence-Based Medicine 94
Vibratory Urticaria (Angioedema) 91 Bibliography 94
12. Atopic Dermatitis . . . . . . . . . . . . . . . . .  . . . . . . . . 95
Satoshi Yoshida, MD, PhD, FACP, FAAAAI, FACAAI
Pathogenesis of Atopic Dermatitis 95 Avoidance of Allergens 100
Immunohistology of atopic Dermatitis 95 Avoidance of Exacerbation Factors 101
Cutaneous Infections: Role for Superantigens 96 Probiotics 101
The Diagnosis of Atopic Dermatitis 97 Topical Corticosteroids 101
Differential Diagnosis 98 Topical Calcineurin Inhibitors 103
Complications 98 Specialized Therapy 104
The Treatment of Atopic Dermatitis 98 Future Perspective 105
Skin Hydration and Moisturizers 99 Evidence-Based Medicine 105
Avoidance of Irritancy 99 Diagnosis 105
Treatment for Pruritus and Deterrent Management (Indirect Outcome) 105
to Skin Scratching 100 Bibliography 105
13. Allergic Contact Dermatitis . . . . . . . . . . . . . . . . . . . . 107
Bettina Wedi, MD, PhD
Definition, Classification, Epidemiology 107 Patch Test Procedure 109
Recognizing Those at Risk 107 Repeat Open Application Test 112
Pathogenesis 107 Angry Back or Excited Skin Syndrome 112
Immunology 107 Pitfalls 112
Histology 108 Management 113
Clinical Symptoms 108 Evidence-Based Medicine 113
Diagnosis 109 Bibliography 114
14. Pediatric Asthma . . . . . . . . . . . . . . .. . . 115
Sixto F. Guiang, MD
Epidemiology of Pediatric Asthma 115 Goals of Treatment 119
Asthma in the Preschool––Age Child 116 Definition of Good Control 119
Natural History of Childhood Asthma 117 Managing Bronchial Asthma in Children 119
Will My Child Outgrow Peak Flow Monitoring 121
the Asthma? 117 Immunotherapy as a Treatment Option 121
Diagnosis of Asthma in the Older Child When does Referral to an Asthma Specialist
or Adolescent 117 Become Desirable? 121
Assessing Severity of the Disease Before Evidence-Based Medicine 122
Initiation of Therapy 118 Bibliography 123
15. Adult Asthma . . . . . . . . . . . . . . . . .  . . . . . . . . 124
Eric C. Chenworth, DO and Daniel E. Maddox, MD
Definition 124 Asthma Exacerbations 130
Epidemiology 124 Maintaining Asthma Control 131
Pathogenesis 124 Special Considerations in the Management
Asthma Diagnosis 125 of Adult Asthma 132
Diagnostic Studies 126 Pregnancy and Asthma 132
Asthma Management 129 Heart Disease and Asthma 132
Classification of Severity 129 Chronic Obstructive Pulmonary Disease and Asthma 132
Management 129 Evidence-Based Medicine 132
Exercise-Induced Asthma 130 Bibliography 133
16. Exercise-Induced Asthma . . . . . . . .  . . . . . . . . . . . . . 134
Laura H. Fisher, MD and Timothy J. Craig, DO
Clinical Characteristics 134 Scuba 142
Diagnosis 135 Hiking 143
Pathophysiology 137 Scuba Diving and EIA: Evidence-Based Medicine 143
Treatment 139 Conclusion 143
Special Considerations 141 Bibliography 143
Olympics 142
17. Occupational Asthma . . . . . . . . . . . . . . . . . . . . . . . . . 145
Jonathan A. Bernstein, MD
Definition 145 Immunologic Assessment 151
Historical Perspective: Incidence and Prevalence 145 Physiologic Assessment 152
Pathogenesis 146 Clinical Assessment of Occupational Asthma 153
Mechanisms of Occupational Asthma 146 Treatment 154
Genetics of Occupational Asthma 146 Prevention and Immunosurveillance 154
Diagnosis of Occupational Asthma 147 Evidence-Based Medicine 155
History 147 Bibliography 155
Differential Diagnosis 148
viii / CONTENTS
18. Asthma and Pregnancy . . . . . . . . . .  . . . . . . . . . . 156
Peg Strub, MD
Adverse Pregnancy Outcomes for Patients Education 158
with Asthma 156 Smoking 158
Physiology 156 Triggers 158
Maternal Respiratory Physiology 156 Treatment Plans 158
Maternal Cardiovascular Physiology 156 Medications 158
Maternal Gastroesophageal Reflux 156 Treatment Guidelines 161
Fetal Physiology 157 Exacerbations 164
Asthma Treatment During Pregnancy 157 Mechanical Ventilation 164
Assessment of Asthma 157 Conclusion 164
Assessment of the Fetus 157 Evidence-Based Medicine 164
Reassurance 158 Bibliography 167
19. Pseudoasthma: When Cough, Wheezing, and Dyspnea Are Not Asthma . . . . . . . . . . . . . . . 168
Miles Weinberger, MD and Mutasim Abu-Hasan, MD
What is Asthma? 168 Partial Airway Obstruction 172
When isn’t it Asthma? 168 Vocal Cord Dysfunction Syndrome 173
Cough that is not Asthma 168 Dyspnea that is not Asthma 173
Other Inflammatory Airway Diseases 168 Hyperventilation 173
Cystic Fibrosis 168 Exertional Dyspnea 173
Tracheomalacia and Bronchomalacia 170 Conclusion 174
Habit Cough Syndrome 171 Evidence-Based Medicine 175
Other Rare Causes of Chronic Cough 171 Bibliography 176
Wheezing that is not Asthma 172
20. Hypersensitivity Pneumonitis . . . . . . .. . . . . . . . . . 177
Joshua Gibbs, DO and Timothy J. Craig, DO
Epidemiology 177 Pulmonary Function Testing 185
Prevalence 177 Bronchoscopy 185
Incidence 177 Histologic Analysis 185
Immunopathogenesis 181 Video-Assisted Thorascopic Surgery 186
Overview 181 Environmental History 186
Acute Phase of Hypersensitivity Pneumonitis 181 Environmental Sampling 186
Subacute Phase of Hypersensitivity Pneumonitis 181 Challenge Methods 187
Chronic Phase of Hypersensitivity Pneumonitis 182 Diagnostic Criteria 187
Clinical Presentation 182 Treatment 187
Acute Presentation 182 Avoidance of Antigen 187
Radiography and Pulmonary Function Testing 183 Environmental Remediation 187
Subacute Presentation 183 Corticosteroids 188
Radiography and Pulmonary Function Testing 183 Prognosis 188
Chronic Presentation 183 Evidence-Based Medicine 188
Diagnosis 183 Conclusion 189
Laboratory Findings 184 Bibliography 189
Radiographic Evaluation 184
21. Allergic Bronchopulmonary Aspergillosis .. . . . . . . 190
Satoshi Yoshida, MD, PhD, FACP, FCCP, FAAAAI, FACAAI
Pathogenesis 190 Treatment 193
Diagnosis 190 Evidence-Based Medicine 194
Staging 191 Diagnosis 194
Radiology 192 Management 194
Laboratory Findings 192 Bibiliography 194
22. Serum Sickness and Immune Complex Disease . . . . . . . . 195
Michael R. Nelson, MD, PhD
Discovery 195 Laboratory 199
Definition 195 Differential Diagnosis 200
Epidemiology 195 Natural History 201
Pathophysiology 196 Management 201
Immune Complexes 196 Monitoring 201
End-Organ Damage Mediated by Therapeutic Options 201
Immune Complexes 197 Prevention 203
Human Disease 197 Future Directions and Evidence-Based Medicine 203
Triggers 197 Conclusion 203
Symptoms and Signs 198 Bibliography 204
Diagnosis 199
Clinical 199
23. Complement Systems and Allergy Diseases . . . . . . . . 206
Marianne Frieri, MD, PhD
The Complement System 206 Autoimmune Urticaria 212
Pathways and Physiologic Activities 206 Complement Therapeutics in Clinical Practice 212
Biologic Properties of Complement Fragments Evidence-Based Medicine 213
Related to Allergic Diseases 206 Bibliography 214
Cellular Receptors and Regulators 208
Clinical Associations 208
Immunomodulation of Autoimmunity
with Intravenous Immune Globulin
and Mechanisms of Immunomodulation 210
24. Food Allergy . . . . . . . . . . . . . . . . . . . . . .  . . . . . . . . 215
Oscar L. Frick, MD, PhD
Mucosal Immunity and Tolerance 215 Prick Skin Tests 218
Pathogenesis 215 In Vitro Tests 219
Allergens 215 Basophil-Degranulation Tests 219
Cross-Reacting Food Allergens 216 Atopy Patch Tests 219
Clinical Manifestations 216 Food Elimination Diets 219
Skin 216 Management and Treatment 220
Gastrointestinal Tract 216 Elimination Diet 220
Respiratory 218 Pharmaceuticals 220
Genitourinary 218 New Experimental Approaches 220
Central Nervous System 218 Hypoallergenic Foods 220
Diagnosis 218 Evidence-Based Medicine 220
Oral Food Challenges 218 Bibliography 220
25. Insect Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Donald F. German, MD, FAAAAI, FACAAI
Stinging insects, Classification, Immunotherapy 226
and Characteristics 222 Reactions to Immunotherapy 227
Venoms 223 Duration of Immunotherapy 227
Insect Sting Reactions, Classification 224 Biting Insect Hypersensitivity 227
Normal Reaction 224 Insect Bite Reactions 228
Toxic Reaction 224 Antigens 228
Local Reactions 224 Immune Response to Insect Bites 228
Systemic Reactions 224 Diagnosis 229
Unusual Reactions 224 Treatment 229
Natural History of Sensitivity 224 The Future 229
Diagnosis 225 Evidence-Based Medicine 229
Treatment of Insect Sting Reactions 225 Bibliography 230
26. Latex Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Donald F. German, MD, FAAAAI, FACAAI
History 231 Diagnosis 232
Epidemiology 231 Management 234
Natural Rubber Latex Products, The Future 234
Production, and Allergens 231 Evidence-Based Medicine 234
Pathogenesis 232 Bibliography 235
27. Drug Allergy . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 236
Schuman Tam, MD, FACP, FAAAAI
Classification 236 Evidence-Based Medicine 243
Type A Drug Reaction 236 Absence of Cross-Reactivity Between Sulfonamide
Type B Drug Reaction 236 Antibiotics and Sulfonamide Nonantibiotics 243
Immunologic Drug Reaction (Drug Allergy) 236 The Risk of a Course of Penicillin Resensitizing the Patient
Immunologic Drug Reaction Based on Gell and with a Positive History but Negative Skin Test Response
Coombs Classification 236 is Low 244
Diagnosis of Drug Reaction/Allergy 238 Recent Advances 245
Clinical Assessment 238 The Role of T Cells in Drug Reaction 245
Diagnostic Investigation 238 Noncovalent Interactions of Drugs with Immune Receptors
Graded Drug Challenge (Test Dosing) 240 May Mediate Drug-Induced Hypersensitivity Reactions 245
Management 240 Diagnostic Testing for T-Cell-Mediated (Type IV)
General Considerations 240 Drug Reaction 245
Desensitization 240 Bibliography 245
Special Considerations 240
28. Smoke, Pollution, and Allergies . . . . . . . . . . . . . . . . . 247
Haig Tcheurekdjian, MD and Massoud Mahmoudi, DO, PhD
Characteristics of Pollutants 247 Diesel Exhaust 250
Indoor Versus Outdoor Pollution 247 Nitrogen Dioxide 250
Actions of Pollution 247 Ozone 251
Characteristics of Individuals 248 Particulate Matter 251
Respiratory Tract Development 248 Sulfur Oxides 252
Immune System Development 249 Conclusion 252
Specific Pollutants 249 Evidence-Based Medicine 252
Tobacco Smoke 249 Bibliography 253
29. Sick Building Syndrome . . . . . . . . . . . . . . . . . . . . . 254
Massoud Mahmoudi, DO, PhD
Is Sick Building Syndrome an Allergic Condition? 254 Characteristics of a Healthy Building Environment 255
Etiology of Sick Building Syndrome 254 How to Prevent Sick Building Syndrome 256
Stachybotrys Chartarum and Human Diseases 254 Management of Sick Building Syndrome 256
Where are the Molds Found? 254 Evidence-Based Medicine 257
Identification of Molds in the Building 254 Bibliography 257
Symptoms 255
30. Allergy in the Elderly . . . . . . . . . . . . . . . . .. . . . . . . 258
Marianne Frieri, MD, PhD
Chronic Rhinitis and Sinusitis 258 Evidence-Based Medicine 261
Asthma in the Elderly 258 Bibliography 261
Other Allergic Conditions 258
Acquired Angioedema, Anaphylaxis,
Food and Drug Allergy 258
CONTENTS / xi
31. Diagnostic Testing in Allergic Diseases . . .  . . . . . . . . . . 262
Paul Cheng, MD, PhD, FAAAAI
Percutaneous Allergy Testing 262 In Vitro Measurement of Allergen-Specific Immunoglobulin E 264
Prick/Puncture Method 262 Allergy Testing with no Proven Value 265
Intradermal Testing 263 Evidence-Based Medicine: Newer Trends in Allergy Testing 265
Diagnostic Value of Percutaneous Allergy Testing 264 Bibliography 265
32. Primary Immunodeficiencies . . . . . . . . . . . . . . . . . . . . . 266
Pedro C. Avila, MD
When to Suspect Immunodeficiency and How Other forms of Combined Cellular and
to Work It Up 266 Humoral Deficiencies 283
Antibody Deficiencies 267 Bare Lymphocyte Syndromes Class I and II 283
X-Linked Agammaglobulinemia 267 Omenn Syndrome 283
Transient Hypogammaglobulinemia of Infancy 270 Wiskott-Aldrich Syndrome 283
Common Variable Immunodeficiency 270 Ataxia Telangiectasia 284
Hyper IgM Syndrome 271 X-Linked Lymphoproliferative Disease or
Other Forms of Hyper-IgM Syndrome Duncan Syndrome 284
(Autosomal Recessive Forms) 272 Phagocyte Deficiencies 284
Selective IgA Deficiency 272 Neutropenic Syndromes 284
Other Antibody Deficiencies 273 Congenital Neutropenia or Kostmann Syndrome 284
Immunoglobulin Replacement Therapy 273 Chédiak-Higashi Syndrome 285
Complement Deficiencies 275 Chronic Granulomatous Disease 285
Laboratory Evaluation of the Other Enzyme Deficiencies 286
Complement System 276 Glucose-6-Phosphatase Dehydrogenase Deficiency 286
Treatment of Complement Deficiencies 277 Myeloperoxidase Deficiency 287
Cellular Immunodeficiencies 277 Hyper-IgE Syndrome or Job Syndrome 287
DiGeorge Syndrome 277 Leukocyte Adhesion Deficiency Type 1 287
Chronic Mucocutaneous Candidiasis 278 Leukocyte Adhesion Deficiency Type 2 288
Immunodysregulation, Polyendocrinopathy, Deficiency in the IL12/IFN-γ Pathway 288
Enteropathy, X-Linked Syndrome 278 Evidence-Based Medicine 288
Autoimmune Lymphoproliferative Syndrome 278 Prenatal Diagnosis 288
Other Cellular Deficiencies 279 Gene Therapy for Immunodeficiencies 288
Combined Cellular and Humoral Bibliography 288
Immunodeficiencies 280 Web-Based Resources 289
Severe Combined Immunodeficiencies 280
33. HIV Infection . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 290
Mitchell H. Katz, MD and Andrew R. Zolopa, MD
Pathophysiology of HIV 290 Hypersensitivity Reactions 297
Immunologic consequences of HIV Infection 290 Immune Reconstitution Inflammatory Syndrome 297
Treatment of HIV Infection 291 Evidence-Based Medicine 298
Antiretroviral Treatment 291 Resources 298
Prophylaxis of Opportunistic Infections 296 Bibliography 298
Treatment of HIV Manifestations 297
34. Complementary and Alternative Medicine in the Treatment
of Allergic and Asthmatic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Jennifer Heimall, MD and Leonard Bielory, MD
What is Complementary and Alternative Medicine? 299 How Modalities have been Studied to Date 300
Definitions and Descriptions of Commonly Identifying Patients most Likely to Use CAM 300
Used Modalities 299 Epidemiology of CAM Use 300
Herbal Therapies 299 Why Patients May Use CAM 301
Homeopathy 299 Identifying Populations Likely to Use CAM 301
Acupuncture 299 Screening for CAM Use by Patients 302
Ayurveda 300
Behavior Modification Techniques 300
Modalities Commonly Used in the Treatment Nontraditional Immunotherapy 304
of Asthma 302 Behavioral Techniques and Behavior Modification 304
Herbals 302 Ethical and Legal Issues Raised by Patient’s Use of CAM 304
Acupuncture 302 Side Effects of CAM 304
Homeopathy 302 Significant Interactions with Western Therapies 307
Behavioral Techniques and Behavior Risks Associated with Lack of Western
Modification 303 Therapeutic Involvement 307
Modalities Commonly Used in the Treatment of Liability Risks for Physicians 308
Allergic Rhinoconjunctivitis 303 Conclusion 308
Herbals 303 Evidence-Based Medicine 308
Acupuncture 303 CAM in the Prevention of Allergic and Asthmatic Disease 308
Homeopathy 304 Bibliography 309
35. Nutrition, Diet, and Allergic Diseases  . . . . . . . . . . . . . . . . . 310
Avraham Giannini, MD
Controlling One’s Destiny 310 Evidence-Based Medicine 313
Historical Perspective 310 Conclusion 313
Dietary Guidelines 311 Bibliography 313
Supplements with an Eye on Allergy 311
36. Prevention and Control Measures in the Management of Allergic Diseases . . . . . . . . . . . . . 315
Shuba Rajashri Iyengar, MD, MPH and Massoud Mahmoudi, DO, PhD
Indoor Allergens 315 Outdoor Allergens 318
Dust Mite 315 Background 318
Control Strategies 315 Control Strategies 319
Animal Dander 316 Evidence-Based Home intervention Methods 319
Cockroach 317 Bibliography 319
Control Strategies 318
37. Antihistamines and Mast Cell Stabilizers . . . . . . . . . . . . . . . . . . . . . . 321
Giselle S. Mosnaim, MD, MS and Timothy J. Craig, DO
Mechanism of Allergic Disease 321 Mast Cell Stabilizers 327
Antihistamine Mechanism of Action 321 Intranasal Chromomes/Mast Cell Stabilizers 327
Antihistamines 321 Intraocular Mast Cell Stabilizers 327
Oral First-Generation Antihistamines 321 Conclusion 327
Oral Second-Generation Antihistamines 322 Evidence-Based Medicine 327
Topical Nasal Antihistamines 326 Bibliography 327
Topical Skin Antihistamines 326
Ocular Antihistamines and Antihistamine/Mast
Cell Stabilizer Combination Products 326
38. Bronchodilators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
Jennifer S. Kim, MD and Rachel E. Story, MD, MPH
Pharmacology of Bronchodilators 329 Devices for Aerosolized Administration
β-Agonists 329 of β-Agonists 331
β-Adrenoreceptors 329 Metered-Dose Inhalers 331
Mechanism of Action and Cellular Effects 329 Nebulizers 331
Structure and Development Dry Powder Inhalers 331
of β-Adrenergic Agents 329 Clinical Use of Bronchodilators for Acute
Short-Acting Nonselective β-Agonists 329 Severe Asthma 332
Short-Acting Selective β2-Agonists 330 Selective Short-Acting β-Agonists 332
Long-Acting Selective β2-Agonists 330 Second-Line Agents for Acute Severe Asthma 332
Enantiomers 330 Long-Acting β2-Agonists 332
Xanthines 330 Long-Term Control Medication Use in Asthma 332
Magnesium Sulfate 330 Short-Acting β-Agonists 332
Routes of Administration for β-Agonists 331 Long-Acting β-Agonists 332
Methylxanthines 333 Evidence-Based Medicine 333
Exercised-Induced Bronchospasm 333 Bibliography 334
Adverse Effects and Safety of β-Agonists 333
Adverse Effects of β-Agonists 333
Safety of β-Agonists 333
39. Glucocorticoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
Joseph D. Spahn, MD
Chemistry 335 Available Inhaled Glucocorticoids 343
Mechanisms of Action 335 Dose/Frequency of Use 343
Systemic Glucocorticoid Therapy 335 Adverse Effects of Inhaled GC Therapy 345
Pharmacokinetics 335 Intranasal Glucocorticoids for the Treatment
Efficacy of Oral Glucocorticoid Therapy of Allergic Rhinitis 346
in Asthma 338 Antiinflammatory Effects 346
Adverse Effects of Chronically Administered Clinical Efficacy 346
Systemic Glucocorticoids 340 Adverse Effects of Nasal Glucocorticoid Therapy 346
Inhaled Glucocorticoid Therapy 342 Conclusion 347
Efficacy of Inhaled Glucocorticoid Therapy 342 Evidence-Based Medicine 347
Inhaled Glucocorticoids as First-Line Therapy 343 Bibliography 348
40. Anti–Immunoglobulin E Therapy . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . 349
Kari C. Nadeau, MD, PhD
Background 349 Other Indications 353
Immunoglobulin E and Inflammation 349 Food Allergy 353
Measurement of IgE for Diagnostic Purposes 350 Allergic Rhinitis 353
Anti-IgE Therapy 350 Atopic Dermatitis 354
Anti-IgE Therapy in Asthma 350 Immunotherapy 354
Studies Using Anti-IgE in Asthma 350 Evidence-Based Medicine 354
Route of Administration 351 Randomized Controlled Study Using Anti-IgE
Efficacy 351 in Rush Immunotherapy 354
Pediatric Trials 352 Use of Anti-IgE Therapy Reduces Leukotrienes in
Studies Using Anti-IgE Therapy in Pediatric Children with Allergic Rhinitis 354
Subjects with Asthma 352 Future Directions 355
Cost-Effectiveness Studies 352 Conclusion 355
Omalizumab Indicated for Treatment of Asthma 353 Bibliography 355
Recommended Dosing 353
Indicated Patient Population 353
41. Allergy Immunotherapy . . . . . . . . . . . . . . . . .. . . . . . . 356
Jeffrey R. Stokes, MD and Thomas B. Casale, MD
Indications 356 Immunotherapy in General Practice 359
Mechanism 356 Efficacy and Outcomes 359
Contraindications 356 Evidence-Based Medicine 360
Dosing 357 Conclusion 360
Safety 358 Bibliography 360
Treatment of Anaphylaxis 359
42. Anaphylaxis and Its Management . . . . . . . . . . . . . . . . 362
Sharon E. Leonard, MD and Lawrence Schwartz, MD, PhD
Definition 362 Latex 364
Pathophysiology 362 Miscellaneous 365
Cells 362 Epidemiology 365
Mediators 363 Overall Incidence 365
Etiology 363 Foods 365
Foods 363 Drugs 365
Drugs 364 Insects 365
Insects 364 Latex 365
Diagnosis and Differential Diagnosis 365 Treatment 367
Signs and Symptoms 365 Acute 367
Time Course 366 Prevention 370
Laboratory Diagnosis 366 Evidence-Based Medicine and Future Directions 370
Differential Diagnosis 367 Bibliography 371
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373



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