The Prior Authorization Task Force of the American Academy of Allergy, Asthma & Immunology (AAAAI), a presidential initiative of David Khan, MD, FAAAI, was established to develop an AAAAI position statement outlining ways to improve health care for our patients, to support legislation that advocates for prior authorization (PA) reform and identify the impact PA has on its membership using a questionnaire survey. This article describes the results of this survey. An electronic anonymous survey questionnaire was developed to assess the impact and burden of PA on AAAAI members and their staff and patients. Surveys were sent to randomly selected members and fellows of the AAAAI in the United States. Descriptive statistics were used to analyze the results by the Information Services team of the AAAAI and the authors of this work group report. The questionnaire responses from allergy immunology specialists demographically reflected the AAAAI membership and indicate that PAs can significantly affect patient care delivery and increase administrative burden to clinical practices, leading to serious adverse events in some circumstances. Differential responses regarding PAs for various medication classes likely reflect the physician’s patient population, which can shift prescribing patterns. Prior authorization is a serious health care problem that is wasting financial resources and needlessly placing patients in danger when they are unable to access medications or medical services required for clinical management. The results of this questionnaire study support the recommendations made in the recent AAAAI position statement on PA.

For clinicians involved in improving healthcare for patients with allergic and immunologic conditions, advocacy on a broader level through public outreach is key to advancing value-based care. In this article, we provide a toolkit of strategies and resources that can be used to raise public awareness of important issues through various mediums, including podcasts and social media, newspapers, testimonies, presentations, and interviews. A simple approach to effective media interactions is described using the acronym "RATIO," which stands for Research, Audience, Targeted topic, Interview rephrasing, and Optimism. The acronym also reminds the person who is presenting information that only a fraction of what is discussed will be recalled, and an even smaller proportion will be implemented. Key points should be made early. Examples of key talking points are provided for selected topics, including food allergy, anaphylaxis, asthma, rhinitis, and broader healthcare advocacy.

Airway immune mediator levels during asthma-like symptoms in young children and their possible role in response to azithromycin

Telemedicine adoption has rapidly accelerated since the onset of the COVID-19 pandemic. Telemedicine provides increased access to medical care and helps to mitigate risk by conserving personal protective equipment and providing for social/physical distancing to continue to treat patients with a variety of allergic and immunologic conditions. During this time, many allergy and immunology clinicians have needed to adopt telemedicine expeditiously in their practices while studying the complex and variable issues surrounding its regulation and reimbursement. Some concerns have been temporarily alleviated since March 2020 to aid with patient care in the setting of COVID-19. Other changes are ongoing at the time of this publication. Members of the Telemedicine Work Group in the American Academy of Allergy, Asthma & Immunology (AAAAI) completed a telemedicine literature review of online and Pub Med resources through May 9, 2020, to detail Pre-COVID-19 telemedicine knowledge and outline up-to-date telemedicine material. This work group report was developed to provide guidance to allergy/immunology clinicians as they navigate the swiftly evolving telemedicine landscape. (C) 2020 American Academy of Allergy, Asthma & Immunology.

To examine the association between early-life gut microbiota and the development of egg allergy.Data from 141 children, 66 with egg allergy and 75 controls, from the multicenter Consortium of Food Allergy Research study from 5 centers were analyzed. Subjects were enrolled from age 3 to 16 months. Baseline characteristics were as follows: 73% white, 67% boys, 39% breastfeeding, and 90% taking solid foods.At enrollment, fecal samples were collected and egg-specific serum immunoglobulin E and egg skin prick tests were performed. To characterize the gut microbiome, 16S ribosomal RNA sequencing was used. Analysis for the primary outcome measure of egg allergy at enrollment and the secondary outcomes of egg sensitization at enrollment and resolution of egg allergy by age 8 years were performed with respect to characteristics of the gut microbiome.Children with egg allergy, when compared with controls, had increased diversity and distinct taxa in the early-life gut microbiome. Genera from the Lachnospiraceae, Streptococcaceae, and Leuconostocaceae were differentially abundant in children with egg allergy. Compared with controls, purine metabolism was decreased in children with egg allergy (Kruskal-Wallis test, adjusted P = 0.021), as assessed by predicted metagenomic function of taxonomic units. Egg sensitization was associated with greater gut microbiome diversity and genera from Lachnosipaceae and Ruminococcaceae. However, among those with egg allergy, there was no association between early-life gut microbiota and egg allergy resolution by age 8 years.This study showed distinguishing characteristics of early-life gut microbiota in children with egg allergy and egg sensitivity.This study provides data that could be helpful in targeting preventive or therapeutic interventions for the development of egg allergy. Alterations in the gut microbiome appear to be present in a variety of allergic diatheses, and there may be a potential for impact through restoring the microbiota to a phenotype that more closely resembles nonallergic controls.

B Sousa-Pinto, L Araujo, A Freitas, L Delgado. Int Arch Allergy Immunol. 2018;176(3–4):234–238 To compare patient characteristics and use of hospital resources in hospitalized children with or without a record of penicillin allergy. The study included all hospitalized children from a database of Portuguese public hospitals from 2000 to 2014. Children labeled as having allergy to penicillin were compared with a similar number of age-, …

The implementation of policies to reduce environmental allergic triggers can be an important adjunct to optimal patient care for allergic rhinitis and allergic asthma. Policies at the local level in schools and other public as well as private buildings can make an impact on disease morbidity. Occupational exposures for allergens have not yet been met with the same rigorous policy standards applied for exposures to toxicants by Occupational Safety and Health Administration. Further benefit may be obtained through policies by local, county, state, and national governments, and possibly through international cooperative agreements. The reduction of allergenic exposures can and should be affected by policies with strong scientific, evidence-based derivation. However, a judicious application of the precautionary principle may be needed in circumstances where the health effect of inaction could lead to more serious threats to vulnerable populations with allergic disease. This commentary covers the scientific basis, current implementation, knowledge gaps, and pro/con views on policy issues in reducing environmental allergic triggers. (C) 2017 American Academy of Allergy, Asthma & Immunology

M Greenhawt, DM Fleischer, ES Chan. Allergy. 2017;72(8):1254–1260 To evaluate data from the Learning Early About Peanut Allergy (LEAP) study to determine the risk factors that most influence peanut tolerance. In the analysis, 640 individuals from the LEAP study (ages 4–11 months with a high risk for allergy) who were included in the data set with complete data, including outcomes of a 60-month oral food challenge, were used. In a secondary analysis, the relationships …

KB Fieten, JEE Totte, E Levin. Int Arch Allergy Immunol. 2018;175(1–2):77–84 To determine whether particular microbial species in the gut are associated with food allergy. Pediatric patients with atopic dermatitis (AD), with or without food allergy and partaking in a Western diet, were included in a cross-sectional observational pilot study. A total of 82 children with AD with a median age of 2.5 years, 20 of whom were diagnosed …

HM Wolsk, BL Chawes, NV Folsgaard. Allergy. 2016;71(6);820–828To determine whether having siblings affects the airway immune response in healthy neonates, a characteristic that could be attributed to an underlying immune modulatory pathway.Five hundred seventy-one 1-month-old, asymptomatic neonates from the Copenhagen Prospective Studies on Asthma in Childhood 2010 (COPSAC2010) birth cohort were studied.Unstimulated airway mucosal lining fluid was sampled via the nose at 1 month …

H Tachimoto, H Mezawa, T Segawa, N Akiyama, H Ida, M Urashima. Allergy. 2016;71(7):1001–1009To assess whether low-dose, short-term vitamin D supplementation in addition to standard treatment improved control of childhood asthma.Eighty-nine Japanese schoolchildren ages 6–15 years who had a diagnosis of asthma based on GINA criteria and spirometry were randomly assigned to receive vitamin D ( n = 54) or a placebo ( n = 35). Ninety-four percent of subjects were using either an inhaled corticosteroid or a leukotriene …

Indoor environmental exposures, particularly allergens and pollutants, are major contributors to asthma morbidity in children; environmental control practices aimed at reducing these exposures are an integral component of asthma management. Some individually tailored environmental control practices that have been shown to reduce asthma symptoms and exacerbations are similar in efficacy and cost to controller medications. As a part of developing tailored strategies regarding environmental control measures, an environmental history can be obtained to evaluate the key indoor environmental exposures that are known to trigger asthma symptoms and exacerbations, including both indoor pollutants and allergens. An environmental history includes questions regarding the presence of pets or pests or evidence of pests in the home, as well as knowledge regarding whether the climatic characteristics in the community favor dust mites. In addition, the history focuses on sources of indoor air pollution, including the presence of smokers who live in the home or care for children and the use of gas stoves and appliances in the home. Serum allergen-specific immunoglobulin E antibody tests can be performed or the patient can be referred for allergy skin testing to identify indoor allergens that are most likely to be clinically relevant. Environmental control strategies are tailored to each potentially relevant indoor exposure and are based on knowledge of the sources and underlying characteristics of the exposure. Strategies include source removal, source control, and mitigation strategies, such as high-efficiency particulate air purifiers and allergen-proof mattress and pillow encasements, as well as education, which can be delivered by primary care pediatricians, allergists, pediatric pulmonologists, other health care workers, or community health workers trained in asthma environmental control and asthma education.

An appropriate goal for managing asthma includes step-down of controller medication to the lowest dose that maintains control. Current recommendations include Expert Panel Report-3 guidelines that state that if asthma remains well controlled for at least 3 months, step-down therapy should be considered to reach a minimum effective controller dose.1EPR-3. Expert panel report 3: guidelines for the diagnosis and management of asthma (EPR-3 2007) (NIH Publication Number 08–05846). U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program, Bethesda, Md2007Google Scholar Nevertheless, there remains uncertainty regarding how best to accomplish this and how to determine the end point for optimal dosing. Because there is significant heterogeneity in asthma severity and in factors determining impairment and risk, an algorithm to manage this goal could be quite complex. Data to evaluate this issue are based mainly on short-term studies that may not adequately assess long-term risk for exacerbations. Studies to address the step-down process in controlled asthma include systematic reviews and meta-analyses of randomized controlled trials and several small, noncontrolled studies.2Gionfriddo M.R. Hagan J.B. Hagan C.R. Volcheck G.W. Castaneda-Guarderas A. Rank M.A. Stepping down inhaled corticosteroids from scheduled to as needed in stable asthma: systematic review and meta-analysis.Allergy Asthma Proc. 2015; 36: 262-267Crossref PubMed Scopus (14) Google Scholar, 3Kew K.M. Beggs S. Ahmed S. Stopping long-acting beta2-agonists (LABA) for children with asthma well controlled on LABA and inhaled corticosteroids.Cochrane Database Syst Rev. 2015; : CD011316PubMed Google Scholar, 4Ahmad S. Kew K.M. Normansell R. Stopping long-acting beta2-agonists (LABA) for adults with asthma well controlled by LABA and inhaled corticosteroids.Cochrane Database Syst Rev. 2015; : CD011306PubMed Google Scholar, 5Rank M.A. Gionfriddo M.R. Pongdee T. Volcheck G.W. Li J.T. Hagan C.R. et al.Stepping down from inhaled corticosteroids with leukotriene inhibitors in asthma: a systematic review and meta-analysis.Allergy Asthma Proc. 2015; 36: 200-205Crossref PubMed Scopus (5) Google Scholar There appears to be an increased risk associated with stopping low-dose inhaled corticosteroids (ICS) compared with decreasing the ICS dose by 25% to 50%.6Rank M.A. Peters S.P. The risks, benefits, and uncertainties of stepping down asthma medications.J Allergy Clin Immunol Pract. 2014; 2: 503-509Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Discontinuation of a long-acting beta-agonist in step-down management from an ICS + long-acting beta-agonist combination therapy has been followed by some loss of asthma control in several studies.7Bacharier L.B. Step-down therapy in asthma: a focus on treatment options for patients receiving inhaled corticosteroids and long-acting beta-agonist combination therapy.Allergy Asthma Proc. 2012; 33: 13-18PubMed Google Scholar, 8Rogers L. Reibman J. Stepping down asthma treatment: how and when.Curr Opin Pul Med. 2012; 18: 70-75Crossref PubMed Scopus (16) Google Scholar, 9Thomas A. Lemanske R.F. Jackson D.J. Approaches to stepping-up and stepping-down care in asthma.J Allergy Clin Immunol. 2011; 128: 915-924Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar Therefore, the selection of patients eligible for step-down therapy and the methods for implementation of step-down therapy along with post–step-down therapy monitoring are key to the effectiveness and optimization of asthma care. Step-down therapy may not be successful if not followed-up with scheduled visits to review inhaler technique, adherence to medications, and environmental control issues. Successful step-down therapy may require additional educational efforts in these areas to get the patient on the least amount of medication that maintains asthma control. These efforts can result in less risk for medication adverse effects as well as less cost. Prospective studies that use standardized approaches within typical practices could provide better data for effectiveness in general practice settings. The study reported by Rank et al10Rank M.A. Liesinger J.T. Branda M.E. Gionfriddo M.R. Schatz M. Zeiger R.S. et al.Comparative safety and costs of stepping-down asthma medication in patients with controlled asthma.J Allergy Clin Immunol. 2016; 137: 1373-1379.e3Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar in this issue of the Journal uses data collected in an administrative database over a 10-year period to measure the effectiveness of step-down therapy in patients with controlled asthma. Individuals 4 years and older with persistent asthma by Healthcare Effectiveness Data and Information Set (HEDIS) criteria were identified from the US Medical Expenditure Panel Survey database from years 2000 to 2010. The cohort included patients who had data available for both years of any 2-year panel survey during the period with data collected at 4- to 5-month intervals comprising 5 periods. The safety and costs of stepping-down asthma controller medication were compared with maintaining the same treatment level in individuals with controlled asthma. For analysis, the authors considered individuals as eligible for step-down therapy if they had no hospitalizations or emergency department visits for asthma in periods 1 to 3, and no systemic corticosteroids and less than 3 rescue inhalers dispensed in periods 2 to 3. There are several key findings and strengths worth highlighting from this study. One advantage to this study is the assessment of effectiveness based on real-world experiences outside of the confines of a clinical trial, a trial in which extra monitoring can be an intervention by itself that may enhance adherence to a particular medication regimen. Second, the authors used a comprehensive 2-year data set within the database from the past decade and used validated definitions of asthma risk and impairment in the assessment for step change and clinical outcomes. Most notable is the finding that similar clinical outcomes were observed at a reduced cost in patients with step-down therapy compared with those who maintained their current treatment. With about 30% of the patients meeting the inclusion criteria for the study eligible for step-down therapy, those who did step-down and had complete asthma control were 89.4% of this cohort compared with 83.5% of those eligible for step-down therapy who maintained their current step level. These high percentages of asthma control demonstrate that the eligibility criteria used in this study for step-down therapy could be appropriate for utilization in community asthma care. Nonetheless, there are some limitations to this study that must be considered in the application of its findings to general practice settings. These include (1) lack of knowledge regarding the precise time and clinical circumstances at the implementation of asthma medication reduction and whether or not this was initiated by the patient or the physician, (2) adherence measured by pharmacy claims data alone, (3) lack of longer follow-up comparisons subsequent to the step-down period that could help determine any potential long-term risk, and (4) lack of number of observations to help compare outcomes for specific step-level changes within step 1 to step 6 categories. Current asthma treatment practices that are more commonly used achieve control quickly and then allow step-down therapy, as opposed to starting at a lower medication dose and stepping-up if needed. The average monthly asthma-related cost savings of $34 a month described by Rank et al10Rank M.A. Liesinger J.T. Branda M.E. Gionfriddo M.R. Schatz M. Zeiger R.S. et al.Comparative safety and costs of stepping-down asthma medication in patients with controlled asthma.J Allergy Clin Immunol. 2016; 137: 1373-1379.e3Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar in the study cohort that was eligible for and achieved step-down, without increasing indirect costs or worsening clinical outcomes, is significant. These findings support the general concept for broad implementation of criterion-based step-down therapy. It is certainly possible that an active, criterion-based approach to step-down therapy, as opposed to the observational results of general asthma care practice determined from this study, could lead to additional cost savings. There is a further need to identify how to accomplish this prospectively in the most effective manner and how best to monitor long-term outcomes. Future research should involve prospective studies that include effectiveness of easily implemented educational interventions in conjunction with step-down therapy. Such interventions could address some of the barriers to optimal asthma control and effective step-down therapy. These barriers may include issues pertaining to beliefs about asthma and beliefs about medicines, scheduling of taking medicines, costs, and environmental factors. Some of these factors can have a significant impact on adherence to a plan. Although population panel studies are suitable for general public health recommendations, it is worth noting that each patient in a cohort may have individual unique characteristics that warrant a tailored patient care plan.11Hagan J.B. Rank M.A. Assessing the risks and benefits of step-down asthma care: a case-based approach.Curr Allergy Asthma Rep. 2015; 15: 503Crossref PubMed Scopus (5) Google Scholar Thus, although an all-encompassing algorithm for step-down therapy is unlikely to be attainable, a more specific guideline could be developed via studies that yield further evidence-based results and then be quite useful. The study by Rank et al10Rank M.A. Liesinger J.T. Branda M.E. Gionfriddo M.R. Schatz M. Zeiger R.S. et al.Comparative safety and costs of stepping-down asthma medication in patients with controlled asthma.J Allergy Clin Immunol. 2016; 137: 1373-1379.e3Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar is a good step in this direction. Comparative safety and costs of stepping down asthma medications in patients with controlled asthmaJournal of Allergy and Clinical ImmunologyVol. 137Issue 5PreviewLimited data exist regarding outcomes after stepping down asthma medication. 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The goal of this study was to identify better ways to characterize microbial exposure early in life as a possible predictor of respiratory symptoms and allergies.A birth cohort of 410 children in Finland was recruited over a 3-year period and followed up until 6 years of age.Asthma, wheezing, cough, and atopic dermatitis were assessed by questionnaires administered during the third trimester and in follow-up at ages 2, 12, 18, and 24 months and yearly thereafter. Dust samples were collected at 2 months of age and analyzed for bacterial endotoxin, 3-hydroxy fatty acids, N-acetyl-muramic acid, fungal extracellular polysaccharides, β-D-glucan, ergosterol, and bacterial or fungal quantitative polymerase chain reaction (qPCR). Specific immunoglobulin E levels to aeroallergens were determined at ages 1 and 6 years.Development of asthma and allergic sensitization were examined, and only a few associations were found with single microbial markers. In contrast, a score for the total quantity of microbial exposure (bacteria and fungi) was significantly associated with asthma incidence (P < .001); the highest risk was found at medium levels (middle portion of an inverted U-shape curve) and the lowest risk was found at the highest level. The microbial diversity score (sum of detected qPCRs) was inversely associated with risk of wheezing and was significantly associated with sensitization to inhalant allergens at age 6 years, but not with atopic dermatitis.This study illustrates that the score for total quantity of microbial exposure predicted asthma better than single microbial markers independently of microbial diversity and amount of dust.Several factors are involved in the relationship between microbial exposure and the development of asthma and allergic sensitization that have been examined in other studies. These include timing relative to age of the subject, amount, duration, and diversity. This study used a unique index of a total microbial quantity score in addition to qPCR assessments of microbial diversity. Further studies with large cohorts in different settings as well as more accurate exposure assessment data will add to the knowledge base that can help better predict risk for the development of asthma and allergies.