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            Allergy and Asthma:
    Improving Outcomes in Primary Care

            Len Fromer, M.D., FAAFP

               The Etiology Challenge

    ►Common symptoms and diseases have
     many possible etiologies
    ►IgE-mediated allergies trigger
     symptoms from infancy into adulthood
    ►Identification of true underlying
     cause is essential for effective management

    The Allergic Inflammatory Response

                 Common Childhood Diseases

    ►The illnesses of the Allergy March
         Atopic dermatitis (eczema)
         GI distress
         Recurrent otitis media
         Allergic rhinitis
         Allergic asthma

    ►The symptoms
       Inflammatory in nature
       Multiple etiologies
       Treated empirically

                                   The Allergy March:
                     A Progression of Seemingly Unrelated Diseases


                                Atopic         GI            Otitis    Allergic   Allergic
                               Dermatitis   Distress        Media      Rhinitis   Asthma


                                                       Time (~years)

                                                           Allergy March

                                                          Prevalence of Atopic Disease

                       Prevalence (%)




                                             1        3       5             10             17
                                                                    Age (years)
                                                 Gastrointestinal          Respiratory   Skin

Saarinen UM, Kajosaari M. Lancet. 1995;346:1065-1069.

                                                                       Allergy March

                                                                         IgE Antibody Level

                                                                                              Birch pollen
                                   (Phadebas RAST Class)

                      Mean score


                                                           1                                  Egg white

                                                               n= 12      29            12
                                                                 0-3     4-9           10 - 15
                                                                           Age (years)

Sigurs N, et al. J Allergy Clin Immunol. 1994;94:757-763.

                               Common Childhood Diseases

        ►Atopic dermatitis (AD)1

               17%-20% prevalence in US, other western countries

               Not necessarily severe reaction (anaphylaxis)

               Driven by early exposure and sensitization

               40% of AD caused by food sensitivity

               Empirical treatment: trials of topicals

1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573.

                                Common Childhood Diseases

        ►GI distress1
               Colic, diarrhea, vomiting, constipation, reflux
               Multiple etiologies:
                   – atopy, infection, intolerance, malabsorption, inflammatory
                     bowel, anatomic defect
               10%-42% of symptomatic patients are atopic2,3
               50%-60% of infants with food sensitivities show GI
                (not necessarily full-blown food allergy)
                    – Empirical treatment: trials of formulas

1. Høst A, Halken S. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:488-494.
2. Australasian Society of Clinical Immunology and Allergy. Adverse reactions to food. Available at:
3. Sicherer SH. Pediatrics. 2003;111:1609-1616.

                            Common Childhood Diseases

      ►Recurrent otitis media (OM)
             26% prevalence in US1
             Key risk factors include attendance in daycare,
              cigarette smoke exposure2
             40%-50% involve atopy3,4
             Common underlying cause = eustachian tube dysfunction
                – Caused by inflammation related to allergy or infection
                – Recurrence = not treating the underlying cause
             Empirical treatment: antibiotics, surgery
1.   Lanphear BP, et al. Pediatrics. 1997;99:1-7.
2.   AAAAI. The Allergy Report. 2000;2:155-161.
3.   Data on file, Pharmacia Diagnostics.
4.   Fireman P. J Allergy Clin Immunol. 1997;99:S787-S797

                         Atopy’s Long-Term Consequences
     ► Nearly 80% of children with AD go on to develop allergic
       rhinitis and/or asthma1

     ► Children with early and long-lasting food sensitization:
            3x more likely to develop allergic rhinitis (AR) than those
             transiently sensitized2
            5x more likely to develop asthma than those transiently

     ► Young wheezers with confirmed atopy are more likely to
       develop asthma3

     1. Leung DYM. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:561-573.
     2. Kulig M, et al. Pediatr Allergy Immunol. 1998;9:61-67.
     3. Martinez FD, et al. J Allergy Clin Immunol 1999;104:S169-S174.

            Knowledge of Etiology Guides Treatment for Today and Tomorrow

       ► Specific IgE testing in children can help the clinician:
            – Identify allergen sensitivities
            – Counsel for avoidance
            – Eliminate or reduce symptoms
            – Reduce medication use (including antibiotics)

       ► Targeting atopy can eliminate symptoms and interrupt the
         Allergy March1-5
            – ETAC: Cetirizine and avoidance halved asthma risk in children with AD1
            – PAT: Immunotherapy significantly reduced asthma risk in children with AR2
            – CCAPPS: Multifaceted avoidance intervention reduced asthma prevalence
               56% in high-risk children5

1.   ETAC® Study Group. Pediatr Allergy Immunol. 1998;9:116-124.
2.   Möller C, et al. J Allergy Clin Immunol. 2002;109:251-256.
3.   Platts-Mills TAE. N Engl J Med. 2003;349:207-208.
4.   Sampson H. Ann Allergy Asthma Immunol. 2004;93:307-308.
5.   Chan-Yeung M, et al. J Allergy Clin Immunol. 2005;116:49-55.

                 Etiology Is Elusive

                Upper Respiratory

     Allergic      Non-allergic
                     Rhinitis          Sinusitis

                              Overlapping Symptoms

     Allergic Rhinitis           Non-allergic Rhinitis   Chronic Sinusitis

        Nasal congestion           Nasal congestion       Nasal congestion

        Rhinorrhea                 Rhinorrhea             Rhinorrhea

        Increased                  Increased              Increased
         secretions                  secretions              secretions

        Sneezing                   Postnasal              Postnasal
                                     drainage                drainage
        Itchy, watery eyes
                                                            Headache

                                                            Facial pain

                    Upper Respiratory Diseases

     ► Allergic rhinitis, non-allergic rhinitis, sinusitis
     ► Symptoms caused by inflammation

         Multiple etiologies, including:
          – Allergic          • Hormonal
          – Anatomic          • Vasomotor
          – Infectious
     ► Usually treated empirically/symptomatically
     ► Depending upon etiology, treatment can/should be different

            Productivity Loss $ per 1000 Employees



                                                                   $187,200 $148,512

                  Allergies            Depression              Hypertension
                  Respiratory          Diabetes                CV Disease

       Comparison of Quality-of-Life in Asthmatic and
                Chronic Rhinitis Patients

                                  Mean Quality-of-Life Score (Scale 1-100)*
                                          Asthma         Chronic Rhinitis
             Health Concept
                                          (n=252)             (n=111)
     Social functioning                      84                  73
     Physical functioning                    80                  89
     Role limitations (emotional)            70                  64
     Role limitations (physical)             66                  61
     Energy/fatigue                          59                 55
     Pain                                    74                 77
     Change in health (1 year)               55                 50

                                   Distribution of URD in US1-3

        ► 39% of total population (115M of 295M) have URD

                                                                                                Allergic Rhinitis


1. AHRQ. Management of allergic and nonallergic rhinitis. May 2002: AHRQ Pub. No. 02-E023.
2. Spector SL, ed. Dialogues in Redefining Rhinitis. 1996;1(1,4):1-16.
3. Allergy Statistics.AAAAI Web site. Available at:

                       Actual Atopy and Antihistamine Use

     Identification of allergic disease among users of antihistamines 1
     ► Allergic rhinitis, non-allergic rhinitis, sinusitis
     ► Study of managed-care
       patients repeatedly prescribed                              35%
       oral antihistamines                                        Etiology
     ► Convenience sample                                                     Etiology

       of 246 evaluated with
       in vitro allergy testing
     ► Results revealed non-atopic
       symptom etiology in 2/3 of patients

1. Szeinbach SL, et al. J Manag Care Pharm. 2004;10(3):234-238.

                                        Non-allergic Rhinitis

        ► Wide array of types and etiologies1,2

              Includes: infectious, vasomotor, hormonal, anatomic,
               occupational, drug-induced

        ► Not caused by IgE-mediated allergic inflammation

              Non-sedating antihistamines and other allergy-targeted therapies
               will not treat underlying cause

1. AAAAI. The Allergy Report. 2000;2:1-31.
2. Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518.

                                                  Allergic Rhinitis

           ► Triggered by seasonal or perennial allergen(s)

           ► Symptoms may include:
                    Nasal congestion, rhinorrhea, increased secretions, sneezing,
                     itchy nose/eyes, watery eyes, coughing, postnasal drip1,2

           ► Cumulative threshold disease3,4:
                    Patients are rarely monosensitized
                    Symptoms emerge after ―allergic threshold‖ has been exceeded

1.   AAAAI. The Allergy Report. 2000;2:1-31.
2.   Dykewicz MS, et al. Ann Allergy Asthma Immunol. 1998;81:478-518.
3.   Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification.1998. Publication 98006.01.
4.   Wickman M. Allergy. 2005;60 (Suppl 79):14-18.

                             Cumulative Threshold Disease1


               Dust mites

               Cat dander

                                Situation A2             Situation B3              Situation C3
                                No avoidance             No avoidance              Avoidance measures
                                measures                 measures                  employed
                                                         Third allergen            Third allergen

1. Pharmacia & Upjohn Diagnostics. The Value of Allergen Identification. 1998. Publication 98006.01.
2. Ciprandi G, et al. J Allergy Clin Immunol. 1995;96:971-979.
3. Boner AL, et al. Clin Exp Allergy. 1993;23:1021-1026.

                                        Support for Avoidance in the
                                     Management of Allergies and Asthma
   ► …It has become clear that early intervention may modulate the natural
     course of atopic disease…the reduction in exposure of high-risk infants to
     food and house-dust mite allergens substantially lowers the frequency of
     allergic manifestations in infancy.‖1 – Halmerbauer, et al.

   ► ―Extensive experience suggests that both drug treatment and
     immunotherapy are more effective if patients also decrease exposure. The
     approach is to identify the allergen source (or sources) to which the patient
     is allergic and to educate patients extensively.‖2 – Platts-Mills, et al.

   ► The NIH, AAAAI, and AAFP urge trigger avoidance as a cornerstone
     of asthma management3-5

1. Halmerbauer G, et al Pediatr Allergy Immunol. 2003;14:10-17.
2. Platts-Mills TAE, et al. J Allergy Clin Immunol. 2000;106(5)787-804 .
3. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051.
4. AAAAI. The Allergy Report. 2000;2:33-109.
5. AAFP. Asthma & Allergy Resource Guide. 2004:11-13

       ► Multiple etiologies
              Caused by inflammation from infection, allergy, structural
               other causes1
              ENT experts use term ―rhinosinusitis‖ due to epithelial continuum
               of sinus/nasal passages1,2

       ► Common comorbidity–often with atopy
              Rarely occurs without concurrent rhinitis2
              >50% of moderate to severe asthmatics have chronic

1. Brook I, et al. Ann Otol Rhinol Laryngol. 2000;109:2-20.
2. AAO-HNS. Fact sheet. ENT Link Web site. Available at:
3. AAAAI. The Allergy Report. 2000;2:7,137-153.

                                    Why Should You Test?
      ► History and physical alone yield a correct diagnosis only
        50% of the time1

      ► Different etiologies demand different treatment approaches

      ► Testing for specific IgE levels can rule in/out atopy

      ► If atopic:
              – NSAs probably drug of choice
              – Testing can help clinician pinpoint offending allergens

      ► If non-atopic:
              – Results will allow you to focus on other etiologies
              – Drugs of choice may include decongestants/steroids
              – Patient can avoid unnecessary/ineffective treatment

1. Homburger HA. Arch Pathol Lab Med. 2004;128:1028-1031.

                      URD Management Options

      Specific IgE-Positive/Abnormal      Specific IgE-Negative/Normal
              Atopic Etiology                 Non-Atopic Etiology

       Specific Allergen Avoidance

     Inadequate Response

     Allergy-Targeted                    Pharmacotherapy
                              Adequate                           Adequate
     Pharmacotherapy                       (allergy-targeted     Response
      (eg, NSAs, LTRAs)                     Rx not helpful)

     Inadequate Response                 Inadequate Response

         Referral?              Stop         Referral?             Stop

                The Experts on Differential Diagnosis of Rhinitis

           ―A positive diagnosis (or diagnoses) should
                     be made before formulating

1. Middleton E, et al, eds. Allergy: Principles & Practice. Vol II, 5th ed. St. Louis, Mo: Mosley-Year Book, Inc; 1998:1007.

               The Experts on Differential Diagnosis of Rhinitis

        ► An expert panel in the area of allergy diagnosis
          recommended selective use of in vitro allergy testing by
          primary care physicians.

        ► According to these experts, in vitro tests1:

              Offer a well standardized alternative to skin testing

              Are easily used by generalist physicians

              Are effective in the diagnosis of allergy

1. Selner JC, et al. Ann Allergy Asthma Immunol. 1999;82:407-412.

               The Experts on Differential Diagnosis of Rhinitis

           ―Allergy [IgE] testing should be considered
             in all patients with a suspected diagnosis
                          of allergic rhinitis.‖1

1. Bierman CW, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, Pa: WB
   Sanders Company; 1995:403-404.

     Etiology Linked to Triggers

                           Overlapping Symptoms

                           ―All that wheezes is not asthma.‖
                               – Chevalier Jackson [1865-1958]

     Allergic Asthma            Non-allergic Asthma              “Bronchitis”

        Wheezing                  Wheezing                        Wheezing

        Cough                     Cough                           Cough

        Dyspnea                   Dyspnea                         Dyspnea

        Chest tightness           Chest tightness

        Rhinitis

        Conjunctivitis

                    Lower Respiratory Diseases

     ► Course and severity affected by inflammation (often caused
       by allergy)
     ► Underlying atopy shown to increase symptoms and
       precipitate exacerbations
     ► A wide range of possible triggers include:
          Allergy
          Occupational exposures
          Infection
          GERD
          Tobacco smoke
          Emotional stress
          Exercise
          Cold weather


        ► Widespread
               7% prevalence (>20 million1) and rising
               73% managed by PCPs2

        ► Allergic vs. non-allergic asthma
               60% of asthmatics have allergic asthma3
               90% of children with asthma also have allergies4

1. NCHS. Asthma prevalence, health care use and mortality 2002. Available at:
2. NCHS. Ambulatory care visits 1999–2000. Available at:
3. Milgrom H. Understanding allergic asthma [AAAAI News Release]. June 18, 2003.
4. HØst A, Halken S. Allergy. 2000;55:600-608.

                                 The ―One Airway‖ Concept

      ► Common inflammatory process links upper and lower

             Asthma and allergic rhinitis commonly co-exist2,3
             In concomitant disease, experts recommend evaluation and
              treatment of one condition to aid management of the other4
             Asthma management guidelines from ARIA,4 the NIH,5 AAFP,6
              and AAAAI7
              encourage treatment of AR (and other URDs) to help control
 1.   Bachert C, et al. Immunol Allergy Clin N Am. 2004;24:19-43.
 2.   Nayak AS. Allergy Asthma Proc. 2003;24:395-402.
 3.   Halpern MT, et al. J Asthma. 2004;41:117-126.
 4.   Bousquet J, et al. Allergic Rhinitis and its Impact on Asthma (ARIA). Allergy. 2002;57:841-855.
 5.   NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051.
 6.   AAFP. Asthma & Allergy Resource Guide. 2004:18.
 7.   AAAAI. The Allergy Report. 2000;2:33,54.

                                    NIH Asthma Guidelines1
     Trigger identification/control is primary management step
     ► ―For at least those patients with persistent asthma on daily
       medications, the clinician should:

           Identify allergen exposures

           Use the patient’s history to assess sensitivity to seasonal

           Use skin testing or in vitro [blood] testing to assess sensitivity
            to perennial indoor allergens

           Assess the significance of positive tests in context
            of the patient’s medical history‖

1. NIH. Guidelines for the Diagnosis and Management of Asthma.1997. NIH publication 97-4051.

                            NIH Asthma Guidelines1 (cont’d)

        ► ―Use skin testing or in vitro testing to determine the
          presence of specific IgE antibodies to the indoor
          allergens to which the patient is exposed year
        ► Allergy testing is the only reliable way to determine
          sensitivity to perennial indoor allergens.‖
        ► For selected patients with asthma at any level of
          severity, detection of specific IgE sensitivity to
          or perennial allergens may be indicated as a basis
          for avoidance, or immunotherapy, or to
          characterize the patient’s atopic status.‖

1. NIH. Guidelines for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4051.

              Knowledge of Symptom Triggers Guides Management

        ► Allergy testing may be conducted along with pulmonary
          function tests and other diagnostic evaluations1

        ► In allergic asthma:
              Confirm atopy and identify specific allergic triggers for avoidance
               counseling, symptom reduction, and control of severity and
               comorbid AR

        ► In non-allergic asthma:
              Rule out atopy to focus on possible non-allergic triggers
              Prevent needless control measures

1. NIH. Practical Guide for the Diagnosis and Management of Asthma. 1997. NIH publication 97-4053.

                        Asthma Management Options

         Specific IgE-Positive/Abnormal        Specific IgE-Negative/Normal
                 Atopic Etiology                   Non-Atopic Etiology

          Specific Allergen Avoidance         Focus on Non-allergic Triggers

     Inadequate Response                             • Allergy Rx not helpful
                                                     • Controller(s)
                                                     • Rescue Rx
     •   Treat AR (eg, NSAs)
     •   LTRAs                   Response
     •   Controller(s)
     •   Rescue Rx                          Inadequate                    Adequate
                                             Response                     Response

     Inadequate Response

            Referral?              Stop     Referral?                       Stop

                What Is Happening to Treatment?

     ► Mechanism of disease is better understood

         Means that treatments are nearer the root cause

     ► Therapeutic specificity is increasing

         Diseases are different and differentiation is key

         The mechanism of action of drugs is more specific than ever

         Diagnostic precision by PCP is necessary
          – New diagnostic technology must be employed

                   Market Review: The Role of Diagnostics in

                             Medications for Respiratory Allergy
                       1st Generation           Non-sedating
      Treatment        Antihistamines          Antihistamines
                                                                        Montelukast          Anti-IgE Vaccine
     Progression                                                          (2002)                   (2003)
                           (1970s)                 (1990s)
                    Antihistamine effect
                                           Antihistamine effect                               Binds to IgE;
     Mode(s) of               +                                        Leukotriene
                                               with very little                           Suppression of IgE
      Action          Anticholinergic                                   antagonist
                                           anticholinergic effect
                                              More specific                                     response
                            effect                                                          Highly specific
                       Non-specific             resolution          Specific resolution
                                                                                              resolution of
                         resolution           of symptoms              of symptoms of
     Treatment                                                                             symptoms due to
                       of symptoms           primarily due to         atopy by blocking
      Results                                                                                IgE response
                       regardless of        atopic etiology —              another
                                                                      Very specific to    only — necessitates
                          etiology          necessitates more        mediator pathway
                                                                           atopy —         perfect diagnosis
                                            specific diagnosis
                                                                     necessitates even
                                             Introduction of           more accurate
     Therapeutic                           ―D‖ formula creates       diagnosis (Doctors     Highly specific
                     Broad (shotgun)
      Approach                                 less specific           report marginal         treatment
                                                 treatment            response for AR
                                                                      with Singulair —
                                                                     could be 65% are
                                                                         not allergic)
        Cost                 $                      $$                     $$$                 $$$$$$

                             Disease Paradigms

     Diabetes Mellitus Type 2

     Hx & PE          lab tests      diet & exercise   pharmacotherapy


     Hx & PE         lipid profile   diet & exercise   pharmacotherapy

     CHDs, URDs, LRDs

     Hx & PE          IgE profile
                                       avoidance       pharmacotherapy

           In-vitro Testing: Gain Knowledge to Guide Treatment

  ► FDA-cleared quantitative measure of specific IgE
  ► Only a single blood draw required
  ► Covered under most insurance plans
  ► Accuracy superior to RASTTM*1
        Next-generation assay offers consistently improved sensitivity,2
        De facto standard, documented in >2,700 peer-reviewed publications3
  ► In vitro blood testing and skin prick testing (SPT) viewed as
  ► In-vitro testing is available throughout the nation from all major reference
    and clinical laboratories, including Quest Diagnostics, NS-LIJ &
* RAST is a trademark of Pharmacia Diagnostics.
1. Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230.
2. Szeinbach SL, et al. Ann Allergy Asthma Immunol. 2001;86:373-381.
3. Johansson SGO. Expert Rev Mol Diagn. 2004;4:273-279.
4. Hamilton RG. In: Pediatric Allergy: Principles and Practice. Mosby-Year Book, Inc; 2003:233-242.

            Solid-phase Protein Binding Capacity Comparison

            • cellulose polymer
            binds almost 150 times
            more protein than a
            passively coated tube,
            well or bead, and about
            250 percent more
            protein than a paper
            disc.                         Solid Phase
H. Drevin, 1989
A. Kober, 2004

               Accuracy of Immunoassays for Specific IgE

                                                                  Line represents minimum acceptable R2
                                                                  performance values
                                              .96 - .98



           Ideal Test (Correlation        Newest generation:                  RAST/                       Alastat/
                 Coefficient)               In-vitro testing                 Modified                   3gAllergyTM**

*The authors noted that regression values below 0.80 reflect poor performance in the ability to correctly detect levels of
specific IgE antibodies. ONLY CAP RAST had consistently acceptable regression values.
**Alastat was recently replaced by 3gAllergy. Studies show 93% agreement between both methods.

Williams PB, et al. J Allergy Clin Immunol. 2000;105:1221-1230.

                  Predictive Value vs. Skin Prick Testing (SPT)*

                         Performance parameters                           In vitro†              SPT

                   Sensitivity (%)                                           87.2                 93.8

                   Specificity (%)                                           90.5                 80.1

                   PPV (%)                                                   91.1                 90.1

                   NPV (%)                                                   86.4                 87.1

                   Clinical Efficiency (%)                                   88.8                 89.2

                   • Authors concluded that In-vitro testing Specific IgE blood test and SPT values both
                     exhibited excellent efficiency1

*Adapted from Reference 1.
†in-vitro Specific IgE blood test was used in this study.

1. Wood RA, et al. J Allergy Clin Immunol. 1999;103:733-779.

                                              Profiles Carefully Designed
      ► Profiles engineered to detect >95% of patients with allergy1-3

      ► Regional respiratory profiles include key indoor/outdoor
        allergens selected according to:
              Geographic pollen patterns
              Regional disease prevalence
              Cross reactivity to other allergens in each inhalant class

      ► Allergy March profiles include key food/inhalant allergens
              Six foods account for 90% of food allergy reactions in children4
              Inhalants include common/cross-reactive indoor and outdoor allergens
              Generally recommended for children ≤6 years of age, based on symptoms

1.   Sampson HA, Ho DG. J Allergy Clin Immunol. 1997;100:444-451.
2.   Yunginger JW, et al. J Allergy Clin Immunol. 2000;105:1077-1084.
3.   Poon AW, et al. Am J Man Care. 1998;4:969-985.
4.   AAAAI. The Allergy Report. 2000;3:69.

                                    Understanding Total IgE1
     ► Total IgE often of little practical value when considered alone
     ► Levels rarely high when specific IgE titers are not
     ► Lacks sensitivity as a rule-out screen:
       Specific IgE levels may be significantly high when total IgE is low/normal
     ► Extremely high total IgE may be seen in some very rare non-atopic
             Certain immunodeficiency diseases (including HIV)
             IgE myeloma
             Drug-induced interstitial nephritis
             Graft-versus-host disease
             Parasitic diseases
             Skin diseases in addition to eczema
             Hyper-IgE syndrome (dermatitis, recurrent pyogenic infection)

1. Fromer LM. J Fam Pract. 2004;suppl:S4-S14.
2. AAAAI. The Allergy Report. 2000;1:35.

                                                       Understanding Total IgE
                                                          Interpretation of Total IgE* Results

                                                                        Total IgE Reading
                                                                   Negative          Positive
                                                                   (Normal)          (Abnormal,

                                                     Negative                          Rare1
                              Specific IgE Reading

                                                                                     Scenario B
                                                                  Scenario A

                                                     Positive       Allergic          Allergic
                                                     (Abnormal,     Patient           Patient
                                                                  Scenario C         Scenario D

*Includes URDs (Upper Respiratory Diseases), CHDs (Childhood Diseases), and LRDs (Lower Respiratory Diseases)
1. AAAAI. The Allergy Report. 2000;1:35.12


     ► Diagnostic precision leads to evidence-based medical care
         Improves patient care
         Creates better patient satisfaction
         Provides more appropriate referrals

     ► In-vitro testing Specific IgE blood test is an accurate test to
       differentiate atopic from non-atopic patients

     ► Experts, specialty organizations, and government agencies support
       allergy testing in primary care

     URD Inhalant



             Allergy and Asthma:
     Improving Outcomes in Primary Care

             Len Fromer, M.D., FAAFP


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