Douglas Mack, MD: Adapting to Evolving Allergy Care


With new immunotherapy data and emerging biologic uses, allergists need to adjust their standards for diagnosis and care in pediatric patients.

The field of pediatric food allergy therapy is evolving, from a therapy-vacant specialty to one with increasing variety. With that influx of treatment options comes an expectation that physicians will adjust their practice.

In an interview with MD Magazine® while at the American College of Allergy, Asthma & Immunology (ACAAI) 2019 Scientific Meeting in Houston, Douglas Mack, MD, a pediatric allergist with McMaster University, explained how the allergy field is changing in both resources and priorities.

MD Mag: How does direct allergy care change with the introduction of new therapies?

Mack: I think this is something that we as clinicians are trying to do—how do we do this? Because I think for years what we've been telling families and doctors is these patients have this food allergy and the only option we had for them was A) avoidance and B) have epinephrine on hand, in case the reaction occurs—and we're going to see you in 2 or 3 years to see if maybe you've outgrown it, but maybe you haven’t.

And what you’ve probably grasped at this conference is that there's so much discussion about food immunotherapy—how can we treat this potentially? Are there ways that we can we can integrate, not avoidance, but giving very small amounts of this—whether it's something called EPIT on the skin, or orally by mouth.

And I think that's something that we are all trying to figure out, how to best integrate this. You know there's an FDA-approved product coming very, very soon. But despite that, we've been doing OIT now for over a decade, and I think that suggests that the need for us to kind of integrate this is really, very high. Patients want an option, and we as clinicians want to be able to offer an option.

And I think that we're no longer in a state of equipoise where we don't know which is better, which is worse. At this point, we now have options to offer our patients, and to me, it's an exciting time. I mean, this is going to be rewriting what we do, what the rest of my career is. So it's very exciting.

MD Mag: Do allergy diagnosis and screening processes have to change along with the care?

Mack: I think this is a really important point, because our diagnostic processes are going to change, because now we are faced with truly putting our money where our mouth is. In the past, we may have had some uncertainty as to whether a patient was allergic or not. Our skin test may have supported that, but we may not have been 100% sure.

But now if we're looking at enrolling these families and these patients into these treatment procedures—these are long-term procedures and they're labor-intensive. This is where our testing, whether it's skin testing or blood testing, starts. But we are doing so many more what we call an oral food challenge, where you actually will give very, very small amounts in about a 2 hour period, to see if that patient is allergic. It's what's called our gold standard. And unfortunately, it hasn't been a major part of the allergy practice.

A recent study from 2012 suggested that 70% of allergists in the United States only performed 1-5 oral food challenges a month. When you think about it, these patients are requiring multiple food challenges—sometimes for the different types of foods that they're allergic to, and are potentially allergic to—before we enroll them into these therapies.

So it’s to the point where—I know this is going to sound crazy—but we do about 12 oral food challenges every day to see if these patients are actually allergic, because the demand is so high.

And our skin tests and our blood tests—it's not that they're not great tests, but they aren't perfect. And I think that the onus is on us now to make sure that, if we are going to enroll this and that, that we have the right diagnosis. And that's exactly what we see.

We see that, fortunately or unfortunately, we're doing a ton more of these or oral food challenges, and that has its own burden on our practices for sure. We need more space, we need more staffing—we have a risk of reaction.

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