Australian Society of Clinical Immunology and Allergy
The Australasian Society of Clinical Immunology and Allergy (ASCIA) was established in 1990 as the peak professional body for allergy and clinical immunology in Australia and Aotearoa New Zealand. ASCIA is a member society of the World Allergy Organisation (WAO) and a specialty society affiliated with the RACP.
ASCIA currently represents 680 members, including clinical immunology and allergy specialists and other health professionals who work in the areas of allergy and clinical immunology.
Download the Australian Society of Clinical Immunology and Allergy's Top-5 recommendations (PDF).
Top-5 recommendations on low-value practices
1. Don’t use antihistamines to treat anaphylaxis. Prompt administration of adrenaline (epinephrine) is the only treatment for anaphylaxis.
Rationale and evidence
Rationale
For emergency treatment of a severe allergic reaction (anaphylaxis) it is important to promptly administer adrenaline (epinephrine) by intramuscular injection using an adrenaline autoinjector if available, or by using adrenaline ampoules and syringe (the latter is only suitable in a medical setting).
There is a high risk of potential harm (disability or death) from anaphylaxis if it is not treated promptly with adrenaline. There are also cost implications from delayed or inappropriate treatment of anaphylaxis, such as additional ambulance, emergency department and hospital costs, as well as additional anxiety for patients and their families or carers.
Antihistamines are recommended for treatment of mild and moderate allergic reactions, including allergic rhinitis (hay fever), but have no role in treating or preventing respiratory and cardiovascular symptoms of anaphylaxis. In particular, oral sedating antihistamines should never be used in patients with anaphylaxis as side effects (drowsiness or lethargy) may mimic some signs of anaphylaxis. Injectable promethazine should not be used in anaphylaxis as it can worsen hypotension and cause muscle necrosis.
For further information go to allergy.org.au/anaphylaxis
Evidence
Cox L, Nelson H, Lockey R et al, Allergen immunotherapy: a practice parameter third update, J Allergy Clin Immunol. 2011 Jan;127(1 Suppl): s1 - 55.
Lieberman P, Nicklas RA, Oppenheimer J, The diagnosis and management of anaphylaxis practice parameter 2010 update, J Allergy Clin Immunol. 2010 Sep;126 (3): 477- 80.e1 - 42.
Andreae, D. and M. Andreae, ‘Should Antihistamines be Used to Treat Anaphylaxis?’, BMJ. 2009;338: b2489.
2. Alternative/unorthodox methods should not be used for allergy testing or treatment.
Rationale and evidence
Rationale
Whilst there is currently no cure for allergy, reliable tests and a range of treatments for allergy are available, which are backed up by scientific studies that demonstrate proven safety and efficacy.
In contrast, numerous studies have demonstrated the uselessness of several alternative/unorthodox methods that claim to test or treat allergy. These methods continue to be promoted in the community and some even make false claims that they can cure allergy. There is also currently no stringent regulation of alternative/unorthodox diagnostic techniques and devices, so they can be “listed” in Australia without having to prove that they work.
There is a risk of potential harm if individuals with allergies are incorrectly diagnosed and inappropriately treated using alternative/unorthodox methods, particularly if they have severe allergies. The costs of alternative/unorthodox methods are significant, and are usually paid for by individuals, with rebates from some private health funds. There are cost implications for healthcare services as well as individuals, as these funds are being directed into non-productive areas, and are therefore not available for more useful medical tests and treatments.
Examples of alternative/unorthodox methods that have been demonstrated to lack evidence for testing or treating allergy include food specific IgG and IgG4 tests, homeopathy, cytotoxic testing and kinesiology.
For further information go to allergy.org.au/patients/allergy-testing
Evidence
Beyer and Teuber, Food allergy diagnostics: scientific and unproven procedures, Curr Opin Allergy Clin Immunol. 2005 Jun;5 (3):261-6.
Antico et al Food-specific IgG4 lack diagnostic value in adult patients with chronic urticaria and other suspected allergy skin symptoms, Int Arch Allergy Immunol. 2011;155(1): 52 - 6.
Bernstein L, Li JT, Bernstein D, et al, Allergy Diagnostic Testing: An Updated Practice Parameter, Ann Allergy Asthma Immunol. 2008 Mar;100(3 Suppl 3): S1 -148.
National Health and Medical Research Council. 2015. NHMRC Information Paper: Evidence on the effectiveness of homeopathy for treating health conditions. Canberra: National Health and Medical Research Council; 2015.
Barton et al 1983, ‘Controversial techniques in allergy treatment’, J Natl Med Assoc. 1983 Aug;75(8):831 - 4.
Garrow, J. S. Kinesiology and food allergy. Br Med J (Clin Res Ed) 1988; 296: 1573 - 4.
3. Allergen immunotherapy should not be used for routine treatment of food allergy – research in this area is ongoing.
Rationale and evidence
Rationale
Research into allergen immunotherapy for food allergy is ongoing and until further work determining safety and efficacy is determined, it should not be performed outside of well-defined medical research studies, as there is a high risk of potential harm in individuals with severe food allergy.
Allergen immunotherapy is currently only recommended for treatment of allergic rhinitis (hay fever) and sometimes allergic asthma due to environmental allergens (such as pollen or dust mites) and for the treatment of stinging insect allergy. Allergen immunotherapy should be considered in appropriate patients when symptoms are severe, the cause is difficult to avoid (such as grass pollen or stinging insects) and medications don't help or cause adverse side effects.
For further information go to allergy.org.au/patients/allergy-treatments
Evidence
NurmatovU, Devereax G, Worth A, et al,Effectiveness and safety of orally administered immunotherapy for food allergies: a systematic review and meta-analysis, Br J Nutr. 2014 Jan 14;111(1):12 - 22.
Lucendo AJ, Arias A & Tenias J, Relation between eosinophilic esophagitis and oral immunotherapy for food allergy: a systematic review with meta-analysis, Ann Allergy Asthma Immunol. 2014 Dec;113(6):624 - 9.
Wang, J. and H. Sampson, ‘Oral and sublingual immunotherapy for food allergy’, Asian Pac J Allergy Immunol. 2013 Sep;31(3):198 - 209.
4. Food specific IgE testing should not be performed without a clinical history suggestive of IgE mediated food allergy.
Rationale and evidence
Rationale
Reliable and proven diagnostic tests for food allergy include skin prick testing, blood tests for food specific IgE antibodies and medically supervised food allergen challenges. Allergy test results should never be used on their own, and must be considered together with the patient's clinical history. In the absence of a history of clinical symptoms, low levels of allergen-specific IgE are usually of little diagnostic significance.
Allergy testing of individuals where there is no evidence that food allergy plays a role in their clinical symptoms increases the likelihood of irrelevant false positive results. This may lead to potential harm due to inappropriate and unnecessary dietary restrictions, with nutritional implications for the individual (particularly in children) and unnecessary fear and anxiety (particularly for the family or carers).
For further information go to allergy.org.au/patients/allergy-treatments
Evidence
Sicherer and Wood, Allergy Testing in Childhood: Using Allergen-Specific IgE Tests, Pediatrics. 2012 Jan;129(1):193 - 7.
Bernstein L, Li JT, Bernstein D, Allergy Diagnostic Testing: An Updated Practice Parameter, Ann Allergy Asthma Immunol. 2008 Mar;100(3 Suppl 3):S1 - 148.
5. Don’t delay introduction of solid foods to infants. ASCIA Guidelines for infant feeding and allergy prevention recommend introduction of solid foods to infants around 6 months of age.
Rationale and evidence
Rationale
This recommendation is consistent with ASCIA Guidelines for infant feeding and allergy prevention (2016), which recommend introduction of solid foods to infants, at around 6 months of age, but not before 4 months (including foods considered to be highly allergenic such as peanut) preferably whilst breast feeding.
It's important to seek medical advice if an allergic reaction occurs and also regarding the safe introduction of foods if an infant has a sibling or parent with food allergy.
This recommendation is also consistent with findings from recent studies, including the LEAP (Learning Early About Peanut Allergy) trials published in the New England Journal of Medicine (NEJM) in 2015 and 2016. The LEAP trials concluded that the early introduction of peanuts significantly decreased (by 80%) the frequency of the development of peanut allergy among children at high risk for this allergy and modulated immune responses to peanuts.
For further information go to allergy.org.au/patients/allergy-prevention
Evidence
Du Toit G, Sayre PH, Roberts G, et al.Effect of avoidance on peanut allergy after early peanut consumption. N Engl J Med. 2016.
Du Toit G, Roberts G, Sayre PH, et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med. 2015 Feb 26;372(9):803 - 13.
Perkin MR, Logan K, Tseng A, et al. Randomised trial of introduction of allergenic foods in breast-fed infants. N Engl J Med. 2016.
Togias A, et al. Addendum guidelines for the prevention of peanut allergy in the United States: Report of the National Institute of Allergy and Infectious Diseases (NIAID) sponsored expert panel. WAO J 2017 10(1): 1.
Turner PJ, & Campbell DE. Implementing primary prevention for peanut allergy at a population level. JAMA. 2017 Feb 13.
