Primary care providers can harness specific IgE testing to improve rhinitis care

Key takeaways:

• Most primary care providers manage rhinitis without diagnostic testing.
• Nearly two-thirds of patients prescribed antihistamines have nonallergic symptoms.
• Inaccurate diagnosis can compromise outcomes.

With allergy season in full swing, primary care providers can expect an increase in patients presenting with rhinitis symptoms.

Common symptoms include coughing, sneezing, a runny or congested nose, and itchy eyes, nose, throat and ears. Depending upon severity, these symptoms can have a detrimental impact on a patient’s quality of life, such as sleep deprivation and poor mental health.

The impact of rhinitis on public health also has economic ramifications, with the condition responsible for an estimated $2 billion to $4 billion in lost productivity each year, caused by absenteeism from work and poor school attendance.

In the U.S., 30% of adults and 40% of children are affected by rhinitis. However, due to overlapping symptoms, it can be difficult for PCPs to determine if a patient has allergic rhinitis (AR), triggered by sensitizations to pollens, for example, or nonallergic rhinitis (NAR), caused by exposure to environmental irritants, such as cigarette smoke.

Without an accurate diagnosis, PCPs are less able to devise effective treatment plans and management strategies to support patients.

Cause and effect

In one study, an estimated two-thirds of patients prescribed antihistamines for suspected allergy symptoms were actually nonallergic.

Establishing the cause of rhinitis symptoms is vital to develop effective, patient-centric management and/or treatment plans. Without an accurate diagnosis, PCPs increase the risk for negative patient impact in the form of unnecessary medication costs, poor symptom management and continued exposure to unknown and potentially avoidable allergens.

If PCPs can identify sensitized allergens and accurately diagnose AR, preventative measures can be taken that limit exposure and reduce symptoms. Accurate diagnosis of AR in patients also informs medication selection to enhance efficacy.

With overlapping symptoms making it difficult for PCPs to distinguish between AR and NAR via clinical assessment alone, diagnostic testing represents the key to unlocking enhanced insight into cause and effect.

For patients seeking answers and improved health outcomes, and for PCPs keen to deliver best practice in patient care, specific IgE testing is an efficient and effective solution for ruling in or ruling out AR.

Embracing best practice

Accurate diagnosis underpins symptom relief for rhinitis and is the bedrock of improved patient care.

In 2020, The Journal of Allergy and Clinical Immunology published a rhinitis practice parameter update recommending that “aeroallergen skin prick testing or serological testing be completed to confirm the diagnosis of allergic rhinitis in a patient with history consistent with AR.”

Despite these guidelines from the Joint Task Force on Practice Parameters, comprising members of the American Academy of Allergy, Asthma & Immunology and the American College of Allergy, Asthma and Immunology, 89% of PCPs continue to manage most of their rhinitis patients without diagnostic testing.

Certified allergists typically perform SPT, but current shortages make accessing this resource challenging. Therefore, embracing specific IgE testing in the primary care setting can lead to more efficient patient care and improved outcomes.

Specific IgE testing provides informative results that indicate the levels of allergen-specific IgE antibodies in a patient’s blood sample. These antibodies are an indicator of allergic sensitization to not just whole allergens but also to a selection of allergen components within a typical respiratory allergen profile.

As such, specific IgE tests, alongside clinical assessment, can support PCPs to achieve a more accurate diagnosis for patients presenting with rhinitis symptoms. Allergies can be ruled out in patients that are not sensitized to the allergens tested and appropriate follow-up care organized.

For patients who are sensitized, PCPs are empowered to develop treatment plans and allergen avoidance strategies with increased confidence, inform appropriate referrals and, in limited scenarios, harness the potential of immunotherapy.

No longer reliant on their best guess, with specific IgE testing, PCPs can utilize data to target intervention and optimize care to deliver improved health outcomes and quality of life for patients.

An improved pathway

Introducing an improved pathway for rhinitis management, bolstered by specific IgE testing, does not need to be a complicated undertaking. In fact, PCPs can order specific IgE testing to support accurate diagnosis and unlock targeted treatment plans and exposure reduction strategies easily, efficiently and cost-effectively.

The improved pathway for rhinitis management can be summarized in several steps:

• The PCP conducts a clinical evaluation of a patient presenting with rhinitis symptoms.
• Where appropriate, the PCP orders a specific IgE blood test respiratory profile.
• The patient has a blood sample drawn at the clinic or a laboratory patient service center.
• The lab processes the sample, testing firstly for sensitization to whole allergens and (where reflex is available and following indication of sensitization to whole allergens) allergen components.
• The lab returns results to the PCP for interpretation.

If the patient’s symptoms are determined to be nonallergic, PCPs can further evaluate (chronic infectious sinusitis, vasomotor rhinitis, etc), and, where required, make referrals to specialists such as ENTs for structural, nonallergic issues.

If the patient’s symptoms are determined to be allergic, PCPs can advise on targeted allergy reduction strategies, prescribe appropriate medications such as antihistamines or intranasal medications, and make informed referrals to specialists — ie, immunotherapy for patients with recalcitrant symptoms or for highly allergic individuals.

It is important to note that levels of specific IgE are relative to individual patients and that patients with low levels of specific IgE can still experience severe reactions.

PCPs also can harness this pathway to carry out regional profile testing, designed to capture relevant pollens, and have a high positive and negative predictive value.

Regional respiratory profiles include a selection of relevant grass, tree and weed pollens that are included based upon regional prevalence and cross-reactivity. This drives efficiencies by limiting the quantity of different trees, weeds and grasses that need to be tested.

In addition to the pollens, regional respiratory profiles include testing for perennial allergens, such as dust mites and, when indicated, pet allergen components. This can facilitate a broader understanding of a patient’s allergic sensitization, allowing for a more comprehensive management plan, aiding with future pet selection, and predicting disease.

Better patient care

Respiratory allergies are increasing in the U.S. population, affecting almost 1 in 6 Americans. Yet overlapping symptoms associated with NAR, alongside a current lack of diagnostic testing at the PCP level, is heightening risk for misdiagnosis.

In turn, this is feeding a best guess approach to managing rhinitis symptoms, culminating in unnecessary use of medication, continued exposure to allergens, avoidable PCP burden, and poorer health outcomes for patients.

To respond to these challenges, and comply with the American Academy of Otolaryngology’s clinical practice guidelines on AR and The Journal of Allergy and Clinical Immunology’s 2020 rhinitis practice parameter update*, it is time to introduce better care pathways that encompass specific IgE testing.

By replacing best guess with best practice, PCPs can ensure accurate diagnosis underpins

treatment plans and management strategies for patients. With the ability to test patients and interpret results independently, instances of misdiagnosis can be reduced and, where relevant, better informed referrals made.

A correct diagnosis is three-fourths the remedy. Where rhinitis is concerned, specific IgE testing has the potential to transform the way we manage this increasingly common condition: promoting more thorough assessment, better targeted intervention and improved patient care.

References:

• Dykewicz MS, et al. J Allergy Clin Immunol. 2020;doi:10.1016/j.jaci.2020.07.007.
• Allergy Insider. https://www.thermofisher.com/allergy/us/en/home.html. Accessed May 13, 2024.
• Seidman MD, et al. Otolaryngol Head Neck Surg. 2015;doi:10.1177/0194599814561600.
• Szeinbach SL, et al. J Manag Care Pharm. 2004;doi:10.18553/jmcp.2004.10.3.234.
• Tran NP, et al. Allergy Asthma Immunol Res. 2011;doi:10.4168/aair.2011.3.3.148.

For more information:

Niti Chokshi, MD, is an allergist and immunologist at as well as co-owner of Complete Allergy and Asthma, Houston. She can be reached at niti.chokshi@complete-allergy.net.