Should You Conduct Allergy Testing for Asthma Patients in Primary Care?
By Lakiea Wright, MD
Every day in the United States, there are approximately 10 asthma-related deaths (Asthma and Allergy Foundation of America, n.d.). Vulnerable populations including minorities, children, and low-income individuals suffer disproportionately from higher asthma morbidity and mortality (Zahran et al., 2018). According to the Centers for Disease Control and Prevention (CDC), asthma was the cause of 1,776,851 emergency department visits in 2016 (CDC, 2019). 43.3% of children with asthma have missed school (CDC, 2018) and people with asthma miss about 14 million work days each year—equaling about $2 billion of indirect costs from the condition (Asthma and Allergy Foundation of America, n.d.). Asthma can have a negative impact on sufferers’ quality of life, which can lead to anxiety and confusion and contribute to poor control.
Asthma itself is a condition of underlying inflammation and airway hyperreactivity (Yawn et al., 2018), and asthma medications like rescue inhalers and inhaled corticosteroids, when appropriately prescribed, target that inflammation. But asthma management needs to go beyond medication. A multifaceted approach to asthma management, including medication, environmental control, and education and counseling, helps to improve outcomes. However, one step that’s often overlooked along the management pathway is testing for the allergic sensitizations that can be the root cause of the inflammation (Yawn et al., 2016).
Up to 60% of adults (Allen-Ramey et al., 2005) and 90% of children with asthma may have allergic triggers (Høst & Halken, 2000). That connection is part of why the Guidelines for the Diagnosis and Management of Asthma recommend specific immunoglobulin E (IgE) testing to look for allergic sensitizations that may be contributing to inflammation. To put that in perspective, by those same guidelines, assessment of allergic triggers—which may be done with specific IgE testing—is considered Category A evidence, while the potential effect of administering the influenza vaccine on reducing the number or severity of asthma exacerbations is Category B evidence (National Asthma Education and Prevention Program, 2007).
With specific IgE blood testing available to order from most national and regional labs, it is easy for primary care providers (PCP) to order such a test for their patients with persistent asthma as part of the initial evaluation, prior to considering a specialist referral.
Asthma treatment in primary care
Approximately three-quarters of people with asthma are treated in a primary care setting (Kwong, Eghrari-Sabet, Mendoza, Platts-Mills, & Horn, 2011). Although skin-prick testing for allergic triggers is mainly performed by allergists, a practical diagnostic tool for PCPs is in-vitro specific IgE testing, which is readily available.
It is essential that PCPs present asthma patients with a full picture of their condition, and that includes a robust discussion of allergic sensitizations. Along with clinical history and a physical examination, specific IgE blood testing can help paint a fuller picture—especially now that allergen testing with component reflex is available for indoor triggers like pet allergens.
A recent retrospective study at Molina Healthcare of South Carolina examined the impact of in-vitro specific IgE testing alone on their pediatric and adult asthma patient population (Shrouds, 2019). After the use of testing, the author found a dramatic reduction in asthma-related healthcare utilization and costs, as well as improved appropriate use of asthma medication. The results included:
- 75% reduction in hospitalizations
- 45% reduction in ED visits
- 28% reduction in systemic steroid prescription fills
- 37% increase in preventive inhaled corticosteroid fills (Shrouds, 2019)
Another study, published in 2019, examined the impact of in-vitro specific IgE allergy testing during asthma-related hospitalization on post-hospitalization disease management outcomes (Brock et al., 2019). The results were promising and included:
- The hazard of an ER visit and requiring systemic corticosteroids fell by 50% in mild asthmatics
- Average time to next ER visit was almost one year in allergy-tested group compared to less than six months in the no-test group
Managing exposure to allergic triggers to control inflammation
When the aim is to reduce days of asthma symptoms and their associated costs, the most effective strategy includes individually tailored environmental control measures. And it’s impossible for healthcare providers to fully tailor an environmental control plan for their patients without the added step of testing for potential underlying allergic triggers (Matsui, Abramson, & Sandel, 2016).
Environmental interventions that target all relevant exposures are more likely to be successful than those that target only one or two exposures—which is why testing, along with history, can play a vital role in ensuring that all sensitizations are accounted for (Matsui et al., 2016).
This kind of exposure management is especially important for children, as they are particularly vulnerable to the effects of indoor environmental exposures. This is due to their physiology, and because any pulmonary effects from childhood may affect a person’s long-term respiratory health outcomes (Matsui et al., 2016).
Environmental control plans can contribute to many positive outcomes for pediatric asthma patients, including:
- 3 fewer symptomatic days per year
- 4 fewer missed school days per year
- 1 fewer unscheduled ED/office visits per year (Morgan et al., 2004)
The risk of inaction
Improving outcomes for asthma patients in a primary care setting can be simple and achievable with the help of in-vitro specific IgE allergy testing. Conversely, the risk of not testing can have serious consequences.
Frequently, asthma patients seek medical care and receive a general asthma diagnosis. Their provider prescribes asthma medications, and then the patient goes home—without a complete picture of what may trigger his or her asthma symptoms.
By adding specific IgE blood testing to this continuum, the outcomes have been shown time and time again to improve. With testing, an asthma patient is able to receive a more specific diagnosis, such as allergic asthma. Test results, along with history and a physical exam, allow for the establishment of an individualized exposure management plan, and the need for appropriate medication use is put into a clearer context. Armed with this knowledge, the patient goes home empowered—and has a better chance of keeping his or her asthma controlled.
Lakiea Wright is a board-certified internist, allergist, and immunologist at Brigham and Women’s Hospital in Boston, and the medical director of U.S. clinical affairs at Thermo Fisher Scientific.
References
Allen-Ramey, F., Schoenwetter, W. F., Weiss, T. W., Westerman, D., Majid, N., & Markson, L. E. (2005). Sensitization to common allergens in adults with asthma. Journal of the American Board of Family Practice, 18(5), 434–439.
Asthma and Allergy Foundation of America. (n.d.). Asthma facts and figures. Retrieved from www.aafa.org/asthma-facts
Brock, J. P., Nussbaum, E., Morphew, T. L., Sandhu, V. S., Marsteller, N. L., Yang, B. S., & Randhawa, I. S. (2019). Allergy evaluation during hospitalized asthma improves disease management outcomes. SN Comprehensive Clinical Medicine, 1, 328–333.
Centers for Disease Control and Prevention. (2018, June 11). Child missed days and activity limitation. Retrieved August 27, 2019, from www.cdc.gov/asthma/asthmadata/child_missed_school.html
Centers for Disease Control and Prevention. (2019, May). Most recent national asthma data. Retrieved August 27, 2019, from www.cdc.gov/asthma/most_recent_national_asthma_data.htm
Høst, A., & Halken, S. (2000). The role of allergy in childhood asthma. Allergy, 55(7), 600–608.
Kwong, K. Y., Eghrari-Sabet, J. S., Mendoza, G. R., Platts-Mills, T., & Horn, R. (2011). The benefits of specific immunoglobulin E testing in the primary care setting. American Journal of Managed Care, 17 (Suppl 17), S447–S459.
Matsui, E. C., Abramson, S. L., & Sandel, M. T. (2016). Indoor environmental control practices and asthma management. Pediatrics, 138(5), e20162589.
Morgan, W. J., Crain, E. F., Gruchalla, R. S., O’Connor, G. T., Kattan, M., Evans, R. III … Inner-City Asthma Study Group. (2004). Results of a home-based environmental intervention among urban children with asthma. New England Journal of Medicine, 351(11), 1068–1080.
National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. (2007, August). Expert panel report 3: Guidelines for the diagnosis and management of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute.
Shrouds, R. (2019). In vitro serum specific IgE testing alone reduces healthcare utilization and costs in South Carolina Medicaid-enrolled members with asthma [white paper]. Waltham, MA: Thermo Fisher Scientific.
Yawn, B. P., & the Allergy and Asthma Task Force. (2018). The Allergy and Asthma Task Force recommendations: The practical application of allergic trigger management to improve asthma outcomes. Waltham, MA: Thermo Fisher Scientific.
Yawn, B. P., Rank, M. A., Cabana, M. D., Wollan, P. C., & Juhn, Y. J. (2016). Adherence to asthma guidelines in children, tweens, and adults in primary care settings: A practice-based network assessment. Mayo Clinic Proceedings, 91(4), 411–421.
Zahran, H. S., Bailey, C. M., Damon, S. A., Garbe, P. L., & Breysse, P. N. (2018). Vital signs: Asthma in children—United States, 2001–2016. Morbidity and Mortality Weekly Report, 67(5), 149–155.