Algorithm reduces need for oral food challenges to diagnose walnut, pecan allergy

Thomas Casale, MD

This study is very relevant for allergists. As a specialty, we are attempting to provide alternative mechanisms to diagnose and manage patients with food allergy. Currently, the oral food challenge is considered the standard. However, this is not only time consuming but, more importantly, puts the patient at risk for having an acute allergic reaction requiring medical intervention. Replacing the oral food challenge with safer tests that can accurately diagnose and determine change in sensitivity over time and with treatment is of paramount importance.

However, it will be difficult for most allergists and primary care physicians at the present time to use the algorithm described by Goldberg and colleagues. The vast majority of PCPs do not do allergen skin test and almost certainly do not do BATs. Although PCPs might order allergen specific immunoglobin E tests, they often refer to allergists for help in interpretation. Even among allergists, the availability of BATs for these allergens is not widespread. Furthermore, there is a need for being able to do the test on basophil's that are not fresh and can be analyzed days later. A commercially available BAT meeting these requirements would greatly enhance the utility of the test.

The algortihm by Goldberg and colleagues, if adopted by clinicians in the U.S., is not the first example of allergy experts from multiple countries using each other’s techniques. American allergy professional medical societies often collaborate with international groups, most commonly the European Academy of Allergy and Clinical Immunology and/or WHO, to develop standards of care. The American Academy of Allergy Asthma and Immunology has a meeting with the European Academy of Allergy and Clinical Immunology on an annual basis to develop joint recommendations on patient care standards. These meetings are referred to as PRACTALL. Occasionally, these meetings discuss differences in guidelines developed by the two groups in order to reach consensus acceptable for both European and American allergists. There are many examples of successes in this regard. All of these meetings have resulted in highly cited documents, and I have been fortunate to be a part of many of these consensus documents.