Background
Methods
Questionnaire and Delphi methodology
1A) | 1B) | ||||
---|---|---|---|---|---|
Items | Mean | Median | % Panellists against | IQ | Result |
Diagnostic approach to a patient with suspected respiratory allergy
| |||||
1- Skin-tests are sufficient for the correct aetiologic diagnosis of patients with respiratory allergy | 3.08 | 3 | 32.26 | 2 |
D
|
2- The size of the wheal is useful in the clinically relevant allergen identification | 3.75 | 3 | 35 | 2.5 |
NC
|
3- A positive skin-test indicates the clinical relevance of the allergenic source | 2.11 | 2 | 9.68 | 1.5 |
D
|
4- The specific IgE determination and quantification help us to establish the clinical relevance of an allergenic source | 6.22 | 7 | 28.33 | 1 |
A
|
5- Molecular diagnosis serves to differentiate primary sensitisation from cross-reactivity | 7.84 | 8 | 6.45 | 1 |
A
|
6- In molecular diagnostic tests, a cut-off that allows us to differentiate relevant allergens does not exist | 6.97 | 7 | 27.42 | 2 |
A
|
7- The patient diagnostic approach must be similar, independent of whether respiratory symptoms are persistent or intermittent | 6.92 | 8 | 25.81 | 3 |
A
|
8- The directed medical history and symptoms-exposure schedule allows us to identify the responsible allergenic source of the patient’s clinic in some cases | 7 | 7 | 11.67 | 0 |
A
|
9- Organ-specific provocation tests are not useful in daily clinical practice due to their difficult interpretation and because they are time consuming | 7.1 | 8 | 16.67 | 1 |
A
|
10a- The polysensitised patient is one who presents sensitisation to various allergenic sources | 7.47 | 8 | 11.67 | 2 |
A
|
10b- The polyallergic patient is one who presents sensitisation with demonstrated clinical relevance | 7.90 | 8 | 8.33 | 1 |
A
|
11- The aerobiological information should include the allergenic load in the environment | 7.42 | 8 | 14.52 | 1 |
A
|
Determinant criteria in immunotherapy prescription
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12- Before immunotherapy prescription to a polysensitised patient, an organ-specific provocation with all suspected relevant allergens must be conducted | 2.4 | 2 | 17.74 | 2 |
D
|
13- Assessment of the intensity of symptoms and medication consumption in relation to allergenic exposure should be habitual practice in immunotherapy prescription | 8.23 | 8 | 1.61 | 1 |
A
|
14- Immunotherapy should only be used based on clinical studies that follow current guidelines | 6.92 | 7.5 | 29.03 | 2.5 |
A
|
15-Immunotherapy prescription is advised only if relevant allergen sources are identified | 7.22 | 7 | 6.67 | 1 |
A
|
Immunotherapy composition
| |||||
16- Enzymatic activity (proteolysis) over others should not be used | 7.6 | 8 | 14.52 | 2 |
A
|
17- It is acceptable to include up to two or three allergens in one vaccine if their relevance is identified | 6.28 | 7 | 28.33 | 2 |
A
|
18- Immunotherapy should include all relevant allergenic sources | 3.63 | 3 | 25 | 1 |
D
|
19- Safety studies of a given extract are applicable to all extracts from identical allergenic sources | 2.31 | 2 | 14.52 | 2 |
D
|
20- Efficacy studies of a given extract are assimilable to all extracts from identical allergenic sources | 2.55 | 2 | 17.74 | 2 |
D
|
21- The extract mixture has a nonspecific positive therapeutic effect despite dosage reduction of included allergens | 4.27 | 5 | 46.67 | 2 |
NC
|
22- If mixtures of several allergenic sources are used in immunotherapy, it is necessary to ensure the effective concentration of each one in the final composition | 7.89 | 8 | 6.45 | 2 |
A
|
24- The dose–response studies are conducted with vaccines from one allergenic source so the results cannot be extrapolated to those of mixtures | 7.16 | 8 | 22.58 | 1.5 |
A
|
2A) | 2B) | ||||
---|---|---|---|---|---|
Items | Mean | Median | % Panellists against | IQ | Result |
Epidemiology
| |||||
25- Knowledge of the predominant type of mites in a geographical area is useful in defining the composition of immunotherapy in an allergic patient. | 7.98 | 8 | 3.23 | 2 |
A
|
26- The moulds with the most epidemiological importance in respiratory allergy are Aspergillus and Alternaria. | 7.74 | 8 | 6.45 | 2 |
A
|
27- In patients with double sensitisation to mites and Alternaria, it is essential know if there is exposure to both sources | 7.18 | 8 | 22.58 | 2 |
A
|
Clinical relevance
| |||||
28- Skin-tests, by themselves, are sufficient for the diagnosis of mite allergy, epithelia and mould. | 3.57 | 3 | 25 | 1.5 |
D
|
29- Skin-tests are sufficient for the immunotherapy prescription to mites, epithelium and mould. | 3.43 | 3 | 26.67 | 2 |
D
|
30- Quantitation of specific IgE in serum against full mite extract adds additional value to the skin-test. | 6.4 | 7 | 26.67 | 1.5 |
A
|
31- In order to know the true sensitisation profile of patients allergic to mites, molecular diagnosis is necessary. | 6.13 | 7 | 38.33 | 2 |
NC
|
32- The specific IgE determination in serum against Der p 1 and Der p 2 is useful if these components have been quantified in the vaccine. | 6.83 | 7 | 20 | 0.5 |
A
|
33- The IgE specific quantification to Dermatophagoides and/or Lepidoglyphus and/or Blomia helps to decide AIT composition. | 6.65 | 7 | 16.67 | 0 |
A
|
34- Alt a1 determination as primary sensitiser to Alternaria is recommended before AIT prescription with this mould. | 6.18 | 7 | 35 | 2 |
NC
|
35- Clinical relevance of double sensitisation to Alternaria and mites may be improved by symptom’s calendar. | 6.2 | 7 | 40 | 2 |
NC
|
Therapeutic strategy (AIT for mite sensitised patients)
| |||||
36-Given the high cross-reactivity between Dermatophagoides pteronyssinus and farinae, the choice of the species present in the vaccine is irrelevant. | 6.45 | 7 | 26.67 | 2 |
A
|
37- Quantification of major molecular components (Der p 1 and Der p 2) in the vaccine is mandatory | 6.92 | 8 | 22.58 | 1 |
A
|
38- In case of sensitisation to Lepidoglyphus or Blomia in a patient allergic to Dermatophagoides, only after proving clinical relevance of these minor mites should a vaccine be indicated. | 7.47 | 8 | 14.52 | 1 |
A
|
39- Vaccines containing minor mites should not be used until efficacy has been proven. | 5.97 | 7 | 40 | 3 |
NC
|
40- In case of true allergy to both a minor mite and Dermatophagoides, a vaccine containing both allergens could be used as a 50% mixture. | 6.25 | 7 | 30 | 2 |
A
|
41- It is not advisable to mix mites with any other different allergenic source due to their proteolytic activity | 6.37 | 7 | 28.33 | 3 |
A
|
Therapeutic strategy (patient allergic to moulds (one or more) and with/without mite allergy)
| |||||
42- Patients allergic to Alternaria only should receive a vaccine containing this allergenic source. | 7.69 | 8 | 11.29 | 2 |
A
|
43- Alternaria vaccine must have its major allergen quantified (Alt a 1) | 7.95 | 8 | 11.29 | 2 |
A
|
44- Immunotherapy with mould mixtures is not indicated. | 7.15 | 7 | 23.33 | 1 |
A
|
Therapeutic strategy (Regarding patients allergic to epithelia with/without other sensitivities)
| |||||
45- There is not sufficient scientific evidence in immunotherapy to epithelia different from cat and dog | 5.02 | 6 | 86.67 | 4 |
NC
|
46- Studies with cat epithelium vaccine have shown clinical efficacy | 7.76 | 8 | 9.68 | 2 |
A
|
47- In case of mite and epithelia sensitisation, both clinically relevant when animal avoidance is not possible, a mixture of both would be advisable. | 3.24 | 3 | 25.81 | 2 |
D
|
48- In case of mite and epithelia sensitisation, both clinically relevant when animal avoidance is not possible, two vaccines should be used | 6.74 | 7.2 | 32.26 | 2 |
A
|
49- In the same situation as previously described, the use of a vaccine containing one allergen could be recommended followed by the consideration for a second AIT | 7.37 | 8 | 19.35 | 2 |
A
|
50- In patients allergic to horse epithelium , when occupational exposure and/or severe impact on quality of life is present, AIT could be considered | 8.16 | 8 | 6.45 | 1 |
A
|
3A) | 3B) | ||||
---|---|---|---|---|---|
Items | Mean | Median | % Panellists | IQ | Result |
Epidemiology
| |||||
51- All olive-grass cosensitised patients are equal if they are from the same geographic area | 2.15 | 2 | 9.68 | 2 |
D
|
52- All olive-grass cosensitised patients are equal if they have the same size wheals | 1.84 | 1 | 4.84 | 1.5 |
D
|
53- The genuine sensitisation components (Phl p 1–5 and Ole e 1) are suitable for identifying phenotypes | 7.1 | 7 | 11.29 | 1 |
A
|
Clinical relevance
| |||||
54- Geographic and aerobiological data are very important in identifying the clinical relevance of olive and grass cosensitised patients | 7.29 | 7 | 11.29 | 1 |
A
|
55- In olive-grass cosensitised patients, skin-tests have major limitations in confirming the clinical relevance | 7.18 | 7.5 | 16.13 | 1 |
A
|
56- A higher level of olive IgE than grass (or vice versa) is useful to highlight the clinical relevance in cosensitised patients | 4.08 | 3 | 45 | 2 |
NC
|
57- Confirmation of true sensitisation to olive or grass requires an IgE against genuine components | 7.56 | 8 | 8.06 | 1 |
A
|
58- The clinical relevance in olive-grass cosensitised patients can only be defined by organ-specific provocation tests | 3.19 | 3 | 25.81 | 2 |
D
|
Therapeutic strategy (Immunotherapy indication)
| |||||
59- The identification of the relevant allergenic source in patients cosensitised to grass and olive is essential before prescribing immunotherapy | 7.98 | 8 | 4.84 | 1 |
A
|
60- The demonstrated efficacy in grass immunotherapy is the same as 50% mixture with olive | 2.92 | 3 | 20 | 1 |
D
|
61- In the case of olive-grass cosensitised patients, it is preferable to formulate personalised mixes (variable percentages of the two extracts) | 4.52 | 5 | 71.67 | 4 |
NC
|
62- As grass and olive are complex extracts, the dosage of individual allergens in immunotherapy would be appropriate | 7.05 | 7 | 10 | 1 |
A
|
63- The olive-grass cosensitised patient should not receive immunotherapy until more efficacy data is obtained | 2.55 | 2 | 14.52 | 2 |
D
|
Therapeutic strategy (Immunotherapy formulation)
| |||||
64- The lack of knowledge of therapeutic doses makes the formulation of mixtures difficult | 6.82 | 7 | 27.42 | 2 |
A
|
65- It is correct to formulate olive-grass personalised mixes depending on the size of the wheal | 2.53 | 2 | 22.58 | 2 |
D
|
66- It is preferable to formulate olive-grass personalised mixes (varying percentages of the two extracts) in proportion to the IgE amount corresponding to the two extracts | 3.72 | 3 | 46.67 | 3.5 |
NC
|
67- If the manufacturer guarantees the individual doses of allergens, mixtures of different Poaceae and olive varieties are irrelevant | 6.95 | 7 | 23.33 | 1 |
A
|
68- Grass and olive personalised mixtures (varying percentages of the two extracts) should never be used | 3.92 | 3 | 30 | 2 |
D
|
4A) | 4B) | ||||
---|---|---|---|---|---|
Items | Mean | Median | % Panellists | IQ | Result |
Epidemiology
| |||||
69- Pollen respiratory allergy does not always have a seasonal character | 7.79 | 8 | 8.06 | 2 |
A
|
70- In the allergologic diagnosis, it is essential to know the allergenic sources and preferential exposure calendars from the geographic area | 8.37 | 8.5 | 0 | 1 |
A
|
71- In the allergologic diagnosis, it is essential to know the sensitisation prevalence to different allergenic molecules from the geographical area | 7.77 | 8 | 6.45 | 2 |
A
|
72- It is essential to know the aerobiology area: more captures are needed | 7.81 | 8 | 8.06 | 2 |
A
|
Clinical relevance
| |||||
73- The diagnosis of allergy to Parietaria can sometimes be hampered by the co-sensitisation to other allergen sources, such as dust mites | 6.84 | 7 | 25.81 | 2 |
A
|
74- Sensitisation to Parietaria pollen represents a major challenge for the establishment of clinical relevance, because pollination coincides with other relevant allergenic sources | 7.35 | 7.5 | 12.9 | 1 |
A
|
75- Clinical data (symptoms, time of symptoms, their duration) and aerobiological data are the most important tools for the diagnosis of primary sensitisation sources in patients sensitised to multiple pollens | 6.85 | 7 | 20 | 1 |
A
|
76- In pollinic polysensitised patients, panallergen skin-tests (profilin, LTP and polcalcin) are useful for selecting relevant allergens | 6.82 | 8 | 25.81 | 2 |
A
|
77- The molecular diagnosis does not provide more information than skin-tests, as most sensitisation is due to relevant molecular allergens rather than panallergens | 4.85 | 3 | 48.33 | 4 |
NC
|
78- In a polysensitised patient, the presence of symptoms during the pollinic period of given pollen does not imply clinical relevance of this allergenic source | 5.22 | 5.5 | 88.33 | 4 |
NC
|
79- Molecular diagnostics is limited by the supply of molecular constituents of low prevalence pollens | 6.87 | 7 | 11.67 | 1 |
A
|
Therapeutic strategy
| |||||
80- Immunotherapy is contraindicated in polysensitised patients with more than two clinically relevant pollen types | 2.66 | 2.5 | 17.74 | 2 |
D
|
81- Patients polysensitised to pollens with polcalcin sensitisation do not benefit from treatment with immunotherapy because they have a higher number of reactions | 4.1 | 5 | 45 | 2 |
NC
|
82- The administration of more than one vaccine could be indicated for patients sensitised to more than one relevant allergenic source | 6.63 | 7 | 20 | 0 |
A
|
83- Immunotherapy prescription with different allergenic sources is only justified in the case that pollination periods from such sources do not coincide | 2.92 | 3 | 22.58 | 1 |
D
|
84- When prescribing immunotherapy with a mixture of several allergenic sources, only those pollens with significant exposure should be considered | 7.07 | 7 | 11.67 | 0 |
A
|
85- In areas where grass and olive are prevalent allergens, if profilin is positive, only grass must be included in the vaccine, although it is also common to find sensitisation to other pollens as well | 4.03 | 3 | 35 | 3.5 |
NC
|
86- If mixtures of several allergenic sources are used in immunotherapy, they should include a higher percentage, depending on the clinical relevance of each geographical area | 4.58 | 5 | 66.67 | 4 |
NC
|
87- Immunotherapy would only be indicated if quality extracts for these pollens exist | 7.81 | 8 | 6.45 | 2 |
A
|
88- The efficacy of immunotherapy is associated with an early indication | 7.31 | 7.5 | 19.35 | 1 |
A
|