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From the Townsend Letter
April 2018

Management of the Allergic Patient:
The Role of Different Diagnostic Tests

by Diego Saporta, MD, and David Hurst, MD, PhD
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Practical Application from Testing an Allergy Patient with an IDT
The information provided by the IDT enables mixing a vaccine whose composition will be in accordance to the level of reactivity for each allergen in each individual patient. For example, a patient's treatment serum might include dust mite allergen at a concentration corresponding to dilution #5 and mold allergen at a concentration of dilution #2. This allows starting immunotherapy treatment with safety but at the same time with efficacy. Patients treated with this technique develop clinical improvement soon after onset of treatment. Because the initial level of reactivity was determined for each allergen, dose advancement usually proceeds without major problems leading to a successful treatment of the different allergic conditions mentioned above. 
Surveys of AAAAI allergists have found cases of mortality during testing or immunotherapy administration.37,38 Patients with asthma are at higher risk for severe reactions during testing and immunotherapy based on that technique.39-41 Fatalities from immunotherapy, although rare, are more common in asthmatics.38,42
A survey of the AAOA members who were using IDT reported no cases of mortality during testing or immunotherapy administration.43 Other studies corroborate the safety profile of the IDT and immunotherapy administration based on results from over 4.2 million injections.44
A relatively common occurrence in an allergy practice is to see patients who, following SPT, were told they had allergic rhinitis and/or asthma and yet were only offered medical intervention. There is no need to do an allergy test in order to prescribe medications. A good history will help the practitioner to plan implementation of environmental control measures in addition to prescribing appropriate medications. The same observation is valid for the patient that less frequently had a combination of a SPT and a single dilution ID test or a blood test with only a few positive results: diagnosis is done and medication is prescribed. Perhaps this may reflect the experience of some allergists that after their patients had been treated for the few allergens discovered by SPT their symptoms responded poorly.
When IDT is utilized and additional "minor" allergens are detected and treated, improvement is then accomplished. Sometimes patients "need" the result of the test to convince them that they really have allergy. Ideally, testing should be reserved for those patients that may benefit from immunotherapy.
Methylation SummitA classic example of this problem is the diagnosis "non-allergic rhinitis." In this case the SPT and the blood test are negative. The patient is offered avoidance of triggers and usual medications.45 These cases are diagnosed as Local Allergic Rhinitis46 or "Non-Allergic Rhinitis with Eosinophilia Syndrome (NARES)"47since both the SPT and the blood test are negative.
Advising patients to avoid triggers and administering medication may well keep the symptoms under control but will not treat the underlying inflammation that can end with airway remodeling, chronic otitis48 and chronic sinusitis which may even require surgery after years of disease. When the clinical diagnosis of allergy by a trained physician does not match the test, the patient is usually deprived of the only treatment that can correct the underlying inflammation. Treating with immunotherapy carries risks, but immunotherapy is the only treatment modality that can change the reactivity level of the affected patient, leading to clinically significant improvement14 or even cure of the underlying inflammation. It has been demonstrated that immunotherapy prevents the development of asthma.49
The essential key to making an accurate and thorough diagnosis of which allergens affect a patient is using a testing method that provides maximum sensitivity with a minimum of false positives while using safe testing techniques. This can only be accomplished with the IDT. The use of serial dilutions in the IDT allows for maximal safety during testing, and enables the practitioner to mix a vaccine that will be highly effective with the least chances of eliciting a reaction during treatment. The authors, like other practitioners from the societies mentioned above, (AAOA, PAAS and AAEM), use IDT and plan immunotherapy according to the results of this test. Patients are tested for dust, animal dander, pollens and molds. With this approach, the authors have treated allergy patients very successfully for many years.

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References .pdf

Dr. Saporta completed his training in 1990 at Columbia Presbyterian Hospital in New York City. He is board certified in otolaryngology and has been a fellow of the American Academy of Otolaryngic Allergy (AAOA) since 2001. His private practice in Elizabeth, New Jersey, is heavily oriented to the management of allergic conditions. Interested in the use of oral vaccines since early in his practice, Dr. Saporta presented a protocol for sublingual immunotherapy at the 64th annual meeting of the AAOA that since then has been successfully used for the management of allergic rhinitis with or without asthma.

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