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Copyright 2014 American Medical Association. All rig hts reserved.

Evidence-Based Evaluation forAllergies toAvoid

Inappropriate Testing, Diagnosis, andTreatment

Inthemidst ofanexaminationroomclutteredwithcray-

ons,coloringbooks,andtoysintendedtopacifyorbribe

children during allergy skin testing, an anxious mother

attendedtoheractive4-year-oldson.Aglanceattheap-

pointment book before walking into the room indi-

catedthatthereasonforthisnewpatientvisitwasfood

allergies. The interview began with theusualwhy are

youherequestion.The mothers response: shewanted

to know what foods her son was really allergic to and

were causing his hyperactivity (attention-deficit/

hyperactivity disorder [ADHD]).

AnInternetsearchhaddirectedhertovariousblogs

and support groups encouraging her to have her son

tested for allergies. She found a physician who prom-

ised that oneeasy blood test could determinethe best

elimination dietto treatADHD.The testresultsshowed

that he wasallergicto many things, most of which he

had eaten on a regular basis without any apparent re-

action. However, she heededthe advice of her Internet

ADHD expert and began to eliminate the foods from

hisdiet.Duringthe officevisit, shesaidthatshe sawno

difference in his behavior on the various elimination

diets.In fact, shethought that hisbehavior had gotten

worse because he could not eat his favorite foods. Yet

shewas worried that reintroducing thefoods might be

harmful.

A reviewof thechildslaboratory resultswouldhave

made anygood allergists heart sink: IgGtests for reac-

tionstomorethan100foods.NotonlyareIgGtestsuse-

lessfor diagnosingallergies,1-4

thereisnoevidencelink-ing allergic reactions to ADHD (or other neurological

disorders, such as autism). A positive IgG test resultfor

a food allergen just means that an individual has been

exposedinotherwords, haseatenthefoodbefore. Be-

cause thechild hadno clinicalhistory consistentwith al-

lergies, no allergy testing should have been done at all.

For anypatientwho didhave a history of allergysymp-

toms, the appropriate allergytesting would have been

for allergen-specific IgE.

Therestofthevisitwasspentreassuringthemother

thatherlittleboydidnothaveanyfoodallergiesandthat

even ifhe did,thiscouldnot be the cause ofhis ADHD.

She could give him his favorite foods againand sheshould ask his pediatrician for some evidence-based

ways to manage hisbehavior. Sheleft theexamination

room appreciative and relieved.

This case illustrateswhathas beencoined thetreat-

menttrap,5 inappropriate testing thatspiralsinto inap-

propriatemanagement. Although theconsequences for

this young boy andhis family were not life threatening,

suchunnecessarytesting nevertheless causesharm, the

monetarycostbeingonly themostobvious.In this case,

a small child underwent unnecessary blood sampling,

never a funevent. A mother wasmadeto worry unnec-

essarilyaboutthefoodthatshe wasfeedingher son; she

was also distracted from searching for more effective

ways to help him.

Unfortunately, thisscenario is repeated day in and

dayoutinallergistsoffices,anditcomesinmanyforms.

The IgG test is the wrong test for allergies, yet IgG al-

lergy testing is often performed. Why? Sometimes the

patientor parent requestsIgG testingafter readingmis-

information on the Internet about a link between any

number of complaints or behaviorsand allergies.In ad-

dition, some nonallergists and laboratories naively or-

der IgG allergy tests because such assays are commer-

cially promoted and available.

When a clinical history of allergy does exist, only

then is it appropriate to pursue testing with allergen-

specific IgE tests. Furthermore, allergen-specific IgE

testing should be limited to allergens suggested by

the clinical history. Ordering a battery of IgE tests in

the absence of a relevant clinical history is as inappro-

priate as ordering IgG allergen tests. Although thereare no data on the annual national health care cost

incurred by inappropriate allergy testing, it is not

uncommon for patients to incur costs of several thou-

sand dollars, not to mention the consequent medical,

economic, and social impacts on patients, families,

and clinicians due to inaccurate diagnosis leading to

inappropriate treatment.

Asa partnerin theAmericanBoardof Internal Medi-

cine FoundationsChoosingWisely initiative, the Ameri-

can Academy of Allergy, Asthma and Immunology has

highlightedtheneedforpatientsandphysicianstoavoid

the aforementioned examples of inappropriate allergy

testing.

6

It is a treatment trap, and our patients de-serve better.

Published Online: June9, 2014.

doi:10.1001/jamainternmed.2014.1413.

Conflict of Interest Disclosures: DrHustonhas

servedon theBoardof Directors of theAmerican

Board of Internal Medicine, theAmerican Board of

Allergyand Immunology, and theAmerican

Academy of Allergy, Asthma and Immunology

[AAAAI])and currently serveson theAccreditation

Councilfor Graduate Medical EducationResidency

Review Committee for Allergyand Immunology and

theAmerican Board of Medical SpecialtiesHealth

andPublic PolicyCommittee. DrCox serveson the

Board of Directorsof theAmerican Board of Allergy

andImmunology andas presidenton theBoardof

Directors of theAAAAI, and theAAAAI/American

College of Allergy, Asthma and ImmunologyJoint

Task Forceon Practice Parameters. Drs Huston and

Coxserved on theAAAAITask Forceon Choosing

Wisely. No otherdisclosuresare reported.

1. Sicherer SH,WoodRA; American Academy of

Pediatrics Section on Allergyand Immunology.

Allergytestingin childhood: usingallergen-specific

IgE tests. Pediatrics. 2012;129(1):193-197.

2. StapelSO,AseroR, Ballmer-Weber BK,et al;

EAACI TaskForce. Testingfor IgG4 against foods is

PERSPECTIVE

David P. Huston, MD

Texas A&M Health

Science Center College

of Medicine,Houston.

LindaS. Cox, MD

Nova Southeastern

University,Fort

Lauderdale,Florida.

Corresponding

Author: DavidP.

Huston, MD,Texas

A&MCollege of

Medicine,TexasA&M

HealthScienceCenter,

2121 W HolcombeBlvd,

Houston, TX 77030

([email protected]).

Opinion

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notrecommendedas a diagnostictool:EAACITask

ForceReport.Allergy. 2008;63(7):793-796.

3. Cox L, Williams B, Sicherer S,et al;American

Collegeof Allergy, Asthma and Immunology Test

Task Force; American Academy of Allergy, Asthma

and Immunology Specific IgE Test Task Force. Pearls

and pitfalls of allergydiagnostic testing: reportfrom

the American Collegeof Allergy, Asthma and

Immunology/American Academy of Allergy, Asthma

and Immunology Specific IgE Test Task Force.AnnAllergy Asthma Immunol. 2008;101(6):580-592.

4. BernsteinIL, Li JT, BernsteinDI, et al;American

Academy of Allergy, Asthma and Immunology;

American Collegeof Allergy, Asthma and

Immunology. Allergydiagnostic testing: an updated

practice parameter. Ann Allergy Asthma Immunol.

2008;100(3)(suppl 3):S1-S148.

5. GibsonR, SinghJP. The Treatment Trap: How the

Overuse of MedicalCareIs Wrecking YourHealth

andWhatYouCan Do to Prevent It. Chicago,IL: IR

Dee.2010.

6. American Academy of Allergy, Asthma and

Immunology. 10 Things Physiciansand Patients

Should Question. http://www.choosingwisely.org

/doctor-patient-lists/american-academy-of-allergy

-asthma-immunology/. Accessed April 28,2014.

Opinion Perspective

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Jama Intern Med 2014 Aug 174(8) 6 Evidence