Correspondence / Ann Allergy Asthma Immunol 112 (2014) 184e185
185
Author response We thank the authors for reading and commenting on our article. Currently, allergen immunotherapy is an etiologic treatment that uses allergen immunomodulation to prevent progression of the disease with long-lasting therapeutic effects.1 With our article, we wanted to emphasize the importance of the disease-causing allergen diagnosis with a focus on parallel pollination allergenic species to ensure correct prescription of specific immunotherapy.2 For years the best methods for making an allergologic diagnosis have been discussed.3 In vitro component-resolved platforms are emerging as a fundamental step in the causal diagnosis process, particularly in polysensitized patients.4 Investigators have promoted prediction models for patient diagnosis, preferentially using determination of serum specific IgE to the detriment of skin tests. Although we partially agree with this approach of copying other medical diagnosis protocols, there are well-known limitations. We recommend the initial use of a sensitive, rapid, nonrisky, and easy diagnostic resource (skin prick test). Then information from the skin prick test should be confirmed and specific IgE determination techniques against purified natural or recombinant allergens performed.5 We recognize that sometimes skin tests are insufficient and IgE molecular studies are required. Cases of wide polysensitization, suspicions of cross-reactivity between inhalants and food, quantitative comparison of sensitizations and anaphylaxis risk degrees, search of primary allergen sensitizer for immunotherapy, sensitization descriptive surveys to configure maps, and even described prediction models of regional allergenic food and inhalants profiles are all clear examples of when skin tests are insufficient6; however, this does not devalue skin test results but just improves them. Our work was conducted applying both techniques with a complementary point of view. We performed initial
discrimination using skin prick tests and final confirmation with specific IgE tests. Results corroborated our initial hypothesis. With the consideration of only 2 parallel pollens and without an additional in vitro diagnostic step, we would have prescribed incorrect immunotherapy in more than 50% of our patients. Therefore, we defend the use of the skin prick test as the first diagnostic tool followed by the support of specific IgE assays. Antonio Letrán, MD Marisa Espinazo, PhD Francisco Moreno, PhD, MD Clínica Dr. Lobatón Cádiz, Spain [email protected]
References [1] Burks AW, Calderon MA, Casale T, et al. Update on allergy immunotherapy: American Academy of Allergy, Asthma & Immunology/European Academy of Allergy and Clinical Immunology/PRACTALL consensus report. J Allergy Clin Immunol. 2013;131:1288e1296. [2] Letran A, Espinazo M, Moreno F. Measurement of IgE to pollen allergen components is helpful in selecting patients for immunotherapy. Ann Allergy Asthma Immunol. 2013;111:295e297. [3] Bernstein IL, Li JT, Bernstein DI, et al. Allergy diagnostic testing: an updated practice parameter. Ann Allergy Asthma Immunol. 2008;100:S1eS148. [4] Sastre J. Molecular diagnosis in allergy. Clin Exp Allergy. 2010;40:1442e1460. [5] Chapman MD, Ferreira F, Villalba M, et al. The European Union CREATE project: a model for international standardization of allergy diagnostics and vaccines. J Allergy Clin Immunol. 2008;122:882e889. [6] Canonica GW, Ansotegui IJ, Pawankar R, et al. A WAO-ARIA-GA2LEN consensus document on molecular-based allergy diagnostics. World Allergy Organ J. 2013; 6:17.
185
Author response We thank the authors for reading and commenting on our article. Currently, allergen immunotherapy is an etiologic treatment that uses allergen immunomodulation to prevent progression of the disease with long-lasting therapeutic effects.1 With our article, we wanted to emphasize the importance of the disease-causing allergen diagnosis with a focus on parallel pollination allergenic species to ensure correct prescription of specific immunotherapy.2 For years the best methods for making an allergologic diagnosis have been discussed.3 In vitro component-resolved platforms are emerging as a fundamental step in the causal diagnosis process, particularly in polysensitized patients.4 Investigators have promoted prediction models for patient diagnosis, preferentially using determination of serum specific IgE to the detriment of skin tests. Although we partially agree with this approach of copying other medical diagnosis protocols, there are well-known limitations. We recommend the initial use of a sensitive, rapid, nonrisky, and easy diagnostic resource (skin prick test). Then information from the skin prick test should be confirmed and specific IgE determination techniques against purified natural or recombinant allergens performed.5 We recognize that sometimes skin tests are insufficient and IgE molecular studies are required. Cases of wide polysensitization, suspicions of cross-reactivity between inhalants and food, quantitative comparison of sensitizations and anaphylaxis risk degrees, search of primary allergen sensitizer for immunotherapy, sensitization descriptive surveys to configure maps, and even described prediction models of regional allergenic food and inhalants profiles are all clear examples of when skin tests are insufficient6; however, this does not devalue skin test results but just improves them. Our work was conducted applying both techniques with a complementary point of view. We performed initial
discrimination using skin prick tests and final confirmation with specific IgE tests. Results corroborated our initial hypothesis. With the consideration of only 2 parallel pollens and without an additional in vitro diagnostic step, we would have prescribed incorrect immunotherapy in more than 50% of our patients. Therefore, we defend the use of the skin prick test as the first diagnostic tool followed by the support of specific IgE assays. Antonio Letrán, MD Marisa Espinazo, PhD Francisco Moreno, PhD, MD Clínica Dr. Lobatón Cádiz, Spain [email protected]
References [1] Burks AW, Calderon MA, Casale T, et al. Update on allergy immunotherapy: American Academy of Allergy, Asthma & Immunology/European Academy of Allergy and Clinical Immunology/PRACTALL consensus report. J Allergy Clin Immunol. 2013;131:1288e1296. [2] Letran A, Espinazo M, Moreno F. Measurement of IgE to pollen allergen components is helpful in selecting patients for immunotherapy. Ann Allergy Asthma Immunol. 2013;111:295e297. [3] Bernstein IL, Li JT, Bernstein DI, et al. Allergy diagnostic testing: an updated practice parameter. Ann Allergy Asthma Immunol. 2008;100:S1eS148. [4] Sastre J. Molecular diagnosis in allergy. Clin Exp Allergy. 2010;40:1442e1460. [5] Chapman MD, Ferreira F, Villalba M, et al. The European Union CREATE project: a model for international standardization of allergy diagnostics and vaccines. J Allergy Clin Immunol. 2008;122:882e889. [6] Canonica GW, Ansotegui IJ, Pawankar R, et al. A WAO-ARIA-GA2LEN consensus document on molecular-based allergy diagnostics. World Allergy Organ J. 2013; 6:17.
