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Medicines to Avoid Before
Allergy Skin Testing
he American Academy of Otolaryngic Beta blockers are a risk factor for more serious and Allergy (AAOA) has developed this clinical treatment resistant anaphylaxis, making the use of beta care statement to assist healthcare providers blockers a relative contraindication to inhalant in determining which medicines patients skin testing.
should avoid prior to skin testing. These medicines areknown to decrease or eliminate skin reactivity, causing a Treatment with omalizumab (anti-IgE antibody) cannegative histamine control. Providers should have a suppress skin reactivity for up to six months.20, 21
thorough understanding of the classes of medicines that Topical calcineurin inhibitors have a variable affect.
could interfere with allergy testing. With proper patient Pimecrolimus22 did not affect histamine testing but
counseling, the goal is to yield interpretable skin results tacrolimus12 did.
without unnecessary medicine discontinuation.
Herbal products have the potential to affect skin prick Antihistamines suppress the histamine response for testing. In the most comprehensive study,23 using a
a variable period of time. In general, first-generation single–dose crossover study, it was felt that common antihistamines can be stopped for 72 hours, however, herbal products did not significantly affect the histamine several types including Cyproheptadine (Periactin) can skin response. However, complementary and other have active histamine suppression for up to 11 days.
alternative medicines do sometimes have a significant Second-generation antihistamines also suppress testing histamine response24 and included butterbur, stinging
for a variable length of time, up to 7 days. Astelin nettle, citrus unshiu powder, lycopus lucidus, spirulina, (Azelastine) nasal spray has been shown to suppress cellulose powder, traditional Chinese medicine, Indian testing for up to 48 hours.1, 2, 3, 4, 5, 6, 7
ayurvedic medicine. Short-term oral corticosteroids (30 mg daily for a week) Leukotriene receptor antagonist did not affect skin do not suppress skin testing.8 There is a difference of
testing.25, 26, 27
opinion about the effects of long-term or relatively high- dose steroids, i.e. greater than 20 mg of prednisone per Selective serotonin reuptake inhibitors (SSRIs) do not day, on the suppression of immediate skin tests.9, 10
affect skin testing.15, 28
Topical glucocorticosteroids can block the histamine Selective norepinephrine reuptake inhibitors (SNRIs) response.11, 12, 13 Application of potent topical steroids
and protein pump inhibitors (PPIs) are felt not to need have been shown to stop the histamine response for up to be discontinued.15
Statements
to three weeks.14
Cyclosporin did not affect skin histamine response.29
Tricyclic antidepressants can suppress the antihistamine
response from 7 to 14 days depending upon the type.15, 16 ACE inhibitors did not affect histamine skin response.30
Healthcare providers should take into consideration that y Clinical
Benzodiazepines should be discontinued for 7 daysbefore the testing and include clonazepam, diazepam, many of these studies are done when the patient is taking one pharmaceutical agent for a short time. It is lorazepam, and midazolam.15 Alprazolam has also been
shown to inhibit skin testing.17
unclear, if a patient is taking multiple pharmaceutical/ herbal agents that alone have a minor effect, wheth- H2 blockers have the potential to suppress histamine er the combination of these drugs could suppress the skin reactions for up to two days and include cimetidine, histamine response. Therefore, it is imperative that the ranitidine, and famotidine.18, 19
provider have a positive skin histamine response before proceeding with diagnostic skin testing. Note: American Academy of Otolaryngic Allergy's (AAOA) Clinical Care Statements attempt to assist otolaryngic allergists by sharing summaries of recommended therapies and practices from current medical literature. They do not attempt to define a quality of care for legal malpractice proceedings. They should not be taken as recommending for or against a particular company's products. The Statements are not meant for patients to use in treating themselves or making decisions about their care. Advances constantly occur in medicine, and some advances will doubtless occur faster than these Statements can be updated. Otolaryngic allergists will want to keep abreast of the most recent medical literature in deciding the best course for treating their patients. www.aaoaf.org aaoa@aaoaf.org 202.955.5010 11130 Sunrise Valley Drive, Suite 100, Reston, VA 20191
Medicines to Avoid Before
Allergy Skin Testing
1 Bernstein, L. et al Allergy Diagnostic Testing: an updated practice parameter.
15 Shah, K.M. et al. Predicting which medicine classes interfere with allergy skin
Annals of Allergy and Asthma Immunology 2008; 100:S18.
testing. Allergy and Asthma Proceedings 2010; 31:477-482.
2 Long, WF., Taylor, RJ., Wagner, CJ., Leavengood, DC., Nelson, HS. Skin test
16 Bousquet, J. et al. Practical guide to skin prick testing in allergy to
suppression by antihistamines and the development of subsensitivity. aeroallergens. Allergy 2012; 67:18-24.
Journal of Allergy and Clinical Immunology 1985; 76:113-7 (111).
17 Duenas-Laita, A. et al. Successful treatment of chronic drug-resistant urticaria
3 Cook, TJ., MacQueen, DM., Wittig, HJ., Thornby, JI., Lantos, RL, Virtue, CM.
without alprazolam. Journal of Allergy and Clinical Immunology 2009; Degree and duration of skin test suppression and side effects with 123:504-505.
antihistamines: a double blind controlled study with five antihistamines. 18 Kupczyk M., Kuprys I., Bochenska-Marciniak M., et al. Ranitidine (150 mg daily)
Journal of Allergy and Clinical Immunology 1973; 51:7107. (111).
inhibits wheal, flare, and itching reactions in skin-prick tests. Allergy Asthma 4 Phillips, MJ., Meyrick Thomas, RH., Moodley, I., Davies, RJ. A comparison of
Proc 2007; 28:711.
the in vivo effects of ketotifen, clemastine, chlorpheniramine and sodium 19 Miller, J. et al. Suppression of immediate skin tests by ranitidine. Journal of
cromoglycate on histamine and allergen induced weals in human skin. Allergy and Clinical Immunology 1989; 84:895-899.
Br J Clin Pharmacol. 1983; 15:277-86. (11a).
Noga O., Hanf G., Kunkel G. Immunological and clinical changes in allergic Almind, M., Dirksen, A., Nielsen, NH., Svendsen, UG. Duration of the inhibitory asthmatics following treatment with omalizumab. Int Arch Allergy Immunol activity on histamine-induced skin weals of sedative and non-sedative 2003; 131:46.
antihistamines. Allergy. 1988; 43:593-6 (111).
Corren J., Shapiro G., Reimann J., et al. Allergen skin tests and free IgE levels Simons, FE., Simons, KJ., Clinical pharmacology of new histamine H1 receptor during reduction and cessation of omalizumab therapy. J Allergy Clin Immunol antagonists. Clin Pharmacokinet. 1999; 15:277-86. (11a).
2008; 121:506.
7 Pearlman, DS., Grossman, J., Meltzer, EO. Histamine skin test reactivity
22 Spergel JM, Nurse N., Taylor P., PameixSpake A. Effect of topical pimecrolimus
following single and multiple doses of azelastine nasal spray in patients with on epicutaneous skin testing. J Allergy Clin Immunol 2004; 114:695.
seasonal allergic rhinitis. Ann Allergy Asthma Immunol. 2003; 91:258-62. (1b).
More, D.R., et al. Herbal supplements and skin testing. Allergy 2003; Slottri, Zweiman B. A controlled study of the effects of corticosteroids on 58:492-494.
immediate skin test reactivity. Journal of Allergy and Clinical Immunology 1974; 54:229-235.
24 Mainardi, T. et al. Journal of Allergy and Clinical Immunology February 2009;
Des Roches, A., Paradis, L., Bougeard, Y.H. et al. Long-term oral corticosteroid therapy does not alter the results of immediate skin allergy prick tests. Journal 25 Hill, S.L., Krouse, J.H. The effects of montelukast on intradermal wheal and
of Allergy and Clinical Immunology 1996; 98(3):522-7.
flare. Otolaryngology Head and Neck Surgery 2003; 129(3):199-203.
10 Olson, R. et al. Skin reactivity to codeine and histamine during prolonged
26 Simons FE, Johnston L., Gu X., Simons KJ. Suppression of the early and late
corticosteroid therapy. Journal of Allergy and Clinical Immunology 1990; cutaneous allergic responses using fexofenadine and montelukast. Ann Allergy 86:153-159.
Asthma Immunol 2001; 86:44.
11 Andersson M., Pipkorn U. Inhibition of the dermal immediate allergic reaction
27 Cudhadaroglu C., Erelel M., Kiyan E., et al. Role of Zafirlukast on skin prick test.
through prolonged treatment with topical glucocorticosteroids. J Allergy Allergol Immunopathol (Madr) 2001; 29:66.
Clin Immunol 1987;79:345.
28 Isik SR, Celikel S., Karakaya G., et al. The effects of antidepressants on the
Gradman J., Wolthers OD. Suppressive effects of topical mometasone furoate results of skin prick tests used in the diagnosis of allergic diseases. Int Arch and tacrolimus on skin prick testing in children. Pediatr Dermatol 2008; 25:26 Allergy Immunol 2011; 154:63. 13 Pipkorn U. Hammarlund A., Enerback L. Prolonged treatment with topical
29 Munro CS, Higgins EM, Marks JM, et al. Cyclosporin A in atopic dermatitis:
glucocorticoids results in an inhibition of the allergen-induced wheal-and-flare therapeutic response is dissociated from effects on allergic reactions. response and a reduction in skin mast cell numbers and histamine content. Br J Dermatol 1991; 124:43.
Clin Esp Allergy 1989; 19:19.
30 Joint Task Force on Practice Parameters, American Academy of Allergy,
14 Narasimha, S.K., Effective topical corticosteroid application frequency and
Asthma and Immunology, American College of Allergy, Asthma and histamine induced wheals. International Journal of Dermatology 2005; Immunology, Joint Council of Allergy, Asthma and Immunology. The diagnosis 44(5):425-427.
and management of anaphylaxis: an updated practice parameter. J Allergy Clin Clinical
Immunol 2005; 115:S483.
Care
Statements

Note: American Academy of Otolaryngic Allergy's (AAOA) Clinical Care Statements attempt to assist otolaryngic allergists by sharing summaries of recommended therapies and practices from current medical literature. They do not attempt to define a quality of care for legal malpractice proceedings. They should not be taken as recommending for or against a particular company's products. The Statements are not meant for patients to use in treating themselves or making decisions about their care. Advances constantly occur in medicine, and some advances will doubtless occur faster than these Statements can be updated. Otolaryngic allergists will want to keep abreast of the most recent medical literature in deciding the best course for treating their patients. www.aaoaf.org aaoa@aaoaf.org 202.955.5010 11130 Sunrise Valley Drive, Suite 100, Reston, VA 20191
11130 Sunrise Valley Drive, Suite 100, Reston, VA 20191 202.955.5010 aaoa@aaoaf.org www.aaoaf.org
Medicines to Avoid Before
Allergy Skin Testing
Suppressant Effects of Drugs on Immediate Skin Tests*
MEDICATIONS
MEAN DAYS
SUPPRESSED
First Generation Antihistamines1 2
Second Generation Antihistamaines
Antihistamine Nasal Sprays
Antihistamine Eye Drops
Tricyclic Antidepressants and Tranquilizers
Histamine2 Antihistamines (H2 Blocker)
Topical Corticosteroids
Medications that DO NOT Need to be Stopped
Prior to Allergy Skin Prick Testing*
Angiotensin-Converting Enzyme (ACE) Inhibitors
Lisinopril
Immunosuppressant
Nasal Steroid Sprays
Beclomethasone Dipropionate Nasal
Fluticasone Furoate Nasal
Mometasone Furoate Nasal
Statements
Norepinephrine Reuptake Inhibitors (SNRIs)
y Clinical
Protein Pump Inhibitors (PPIs)
Serotonin Reuptake Inhibitors (SNRIs)
*See prior references1 Some exceptions see prior references
Note: American Academy of Otolaryngic Allergy's (AAOA) Clinical Care Statements attempt to assist otolaryngic allergists by sharing summaries of recommended therapies and practices from current medical literature. They do not attempt to define a quality of care for legal malpractice proceedings. They should not be taken as recommending for or against a particular company's products. The Statements are not meant for patients to use in treating themselves or making decisions about their care. Advances constantly occur in medicine, and some advances will doubtless occur faster than these Statements can be updated. Otolaryngic allergists will want to keep abreast of the most recent medical literature in deciding the best course for treating their patients. www.aaoaf.org aaoa@aaoaf.org 202.955.5010 11130 Sunrise Valley Drive, Suite 100, Reston, VA 20191

Source: http://www.aaoaf.org/PDF/Clinical%20Statements/2015%20Clinical%20Care%20Statements%20Medicines%20to%20Avoid%20Before%20Allergy%20Skin%20Testing.pdf

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PJ Nicholoff Steroid Protocol Background/Assessment Normal basal secretion of cortisol from the adrenal gland is approximately 5-7 mg/m2/day or 8 -10 mg/day for adults. This amount increases during minor il nesses or surgery to approximately 50 mg/day (5x normal physiologic secretion). These smal increases with uncomplicated surgery return to baseline in 24 hours. Procedures producing greater surgical stress, have been shown to increase cortisol responses to 75-150 mg/day (10x normal physiologic secretion), which return to baseline in about 5 days. Corticosteroids are prescribed for multiple diagnoses to a wide variety of patients. Long term administration of corticosteroids may lead to suppression of the hypothalamic-pituitary-adrenal (HPA) axis. Rapid reduction or abrupt withdrawal of corticosteroid therapy that has been prolonged or at high doses can cause secondary adrenal insufficiency (suppression of the HPA axis), and steroid withdrawal or deprivation syndrome. Recovery from suppression of the HPA axis after discontinuing corticosteroids can be prolonged (possibly 6 to 12 months) and may vary based on doses, dosing schedules and duration of corticosteroid therapy. Since there is a great deal of individual variability in susceptibility to suppression of the HPA axis after chronic use of exogenous corticosteroids, it is not possible to predict with confidence which patients wil be affected. Current practice is to administer supplemental (stress) doses of corticosteroids to patients with suspected suppression of the HPA axis in the perioperative period and during acute il ness to prevent acute adrenal insufficiency, or adrenal crisis. Defining HPA Suppressed Patients: Recommendations differ slightly in defining a suppressed patient, but general guidelines are below (Table 1):

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