Guideline
Update of the S2k guideline on the management of IgE-mediated food allergies
Margitta Worm, Imke Reese, Barbara Ballmer-Weber, Kirsten Beyer, Stephan C. Bischoff, Barbara Bohle, Knut Brockow, Martin Claßen, Peter J. Fischer, Eckard Hamelmann, Uta Jappe, Jörg Kleine-Tebbe, Ludger Klimek, Berthold Koletzko, Lars Lange, Susanne Lau, Ute Lepp, Vera Mahler, Katja Nemat, Martin Raithel, Joachim Saloga, Christiane Schäfer, Sabine Schnadt, Jens Schreiber, Zsolt Szépfalusi, Regina Treudler, Martin Wagenmann, Thomas Werfel, and Torsten Zuberbier
Volume 5 (2021) p. 195 - 243
Abstract
Allergologie select, Vol. 5/2021 (195-243)
Update of the S2k guideline on the management of IgE-mediated food allergies
Margitta Worm1, Imke Reese2, Barbara Ballmer-Weber3, Kirsten Beyer4, Stephan C. Bischoff5, Barbara Bohle6, Knut Brockow7, Martin Claßen8, Peter J. Fischer9, Eckard Hamelmann10, Uta Jappe11#12, Jörg Kleine-Tebbe13, Ludger Klimek14, Berthold Koletzko15, Lars Lange16, Susanne Lau4, Ute Lepp17, Vera Mahler18, Katja Nemat19, Martin Raithel20, Joachim Saloga21, Christiane Schäfer22, Sabine Schnadt23, Jens Schreiber24, Zsolt Szépfalusi25, Regina Treudler26, Martin Wagenmann27, Thomas Werfel28, and Torsten Zuberbier29
1Allergology and Immunology, Department of Dermatology, Venereology, and Allergology, Charité – Universitätsmedizin Berlin, Germany, 2Nutritional Counseling and Therapy, Focus on Allergology, Munich, Germany, 3University Hospital Zurich, Department of Dermatology, Zurich, Switzerland, and Cantonal Hospital St. Gallen, Department of Dermatology and Allergology, St. Gallen, Switzerland, 4Clinic of Pediatrics m. S. Pneumology, Immunology and Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Germany, 5Institute of Nutritional Medicine and Prevention, University of Hohenheim, Stuttgart, Germany, 6Institute of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Austria, 7Department of Dermatology and Allergology, Biederstein, Klinikum rechts der Isar, Technical University of Munich, Germany, 8Klinik für Kinder und Jugendmedizin/Päd. Intensivmedizin, Eltern-Kind-Zentrum Prof. Hess Klinikum Bremen-Mitte, 9Practice for Pediatric and Adolescent Medicine m. S. Allergology and Pediatric Pneumology, Schwäbisch Gmünd, 10University Clinic for Pediatric and Adolescent Medicine, Evangelisches Klinikum Bethel gGmbH, Bielefeld, 11Research Group Clinical and Molecular Allergology, Research Center Borstel, Airway Research Center North (ARCN), member of the German Center for Lung Research (DZL), Borstel, 12Interdisciplinary Allergy Outpatient Clinic, Medical Clinic III, University Hospital Schleswig-Holstein, Lübeck, 13Allergy and Asthma Center Westend, Berlin, 14Center for Rhinology and Allergology, Wiesbaden, 15Pediatric Clinic and Pediatric Polyclinic, Dr. von Haunersches Kinderspital, Department of Metabolic and Nutritional Medicine, Ludwig-Maximilians-University, Munich, 16Pediatric and Adolescent Medicine, St.- Marien-Hospital, Bonn, 17Practice for Pulmonary Medicine and Allergology, Buxtehude, 18Paul-Ehrlich-Institut, Langen, 19Practice for Pediatric Pneumology/Allergology at the Children’s Center Dresden (Kid), Dresen, 20Medical Clinic II, Malteser Waldkrankenhaus, Erlangen, 21Department of Dermatology, University Medical Center, Johannes Gutenberg-University Mainz, 22Nutritional Therapy, Focus on Allergology and Gastroenterology, Schwarzenbek, Germany, 23German Allergy and Asthma Association, Mönchengladbach, Germany, 24Pneumology, University Hospital of Otto von Guericke University, Magdeburg, Germany, 25University Hospital for Pediatrics and Adolescent Medicine, Medical University of Vienna, Austria, 26Clinic of Dermatology, Venereology and Allergology, University Medical Center Leipzig, Germany, 27Nose and Throat Clinic, University Hospital Düsseldorf, Germany, 28Clinic of Dermatology, Allergology and Venerology, Hannover Medical School, Germany, and 29Department of Dermatology, Venerology and Allergology, Charité – Universitätsmedizin Berlin
Correspondence to:
Univ.-Prof. Dr. med. Margitta Worm, Allergologie und Immunologie, Klinik für Dermatologie, Venerologie, und Allergologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin
Email: [email protected]
Review
FPIES: Data for Germany in international comparison
Sunhild Gernert, Antje Finger, and Lars Lange
Volume 6 (2022) p. 233 - 240
Abstract
Allergologie select, Vol. 6/2022 (233-240)
FPIES: Data for Germany in international comparison
Sunhild Gernert1, Antje Finger1,2, and Lars Lange1
1GFO Kliniken Bonn, St. Marien-Hospital, Department of Pediatrics, Bonn, and 2Helios University Hospital Wuppertal, Center for Pediatric and Adolescent Medicine, Wuppertal, Germany
Food protein-induced enterocolitis syndrome (FPIES) is a rare, non-IgEmediated food allergy. The triggering foods differ significantly from the typical triggers of an IgE-mediated food allergy. Until recently, there were no data on triggers of FPIES in Germany. In order to create an advisory basis for the care of German patients, a large multicenter study was initiated and published at the end of 2021. This revealed clear differences in international comparisons. The most frequent triggers for FPIES in Germany are cow’s milk, fish, vegetables, and meat. Most children (84%) react to only one food. The prognosis is usually good, depending on the trigger. Regional data should be used for counseling patients with FPIES. Specific recommendations for this are given in this article.Correspondence to:
Dr. Sunhild Gernert, Abteilung für Pädiatrie, GFO-Kliniken Bonn, Sr. Marien-Hospital, Robert-Koch-Str. 1, 53115 Bonn
Email: [email protected]
Guideline
Guideline for allergological diagnosis of drug hypersensitivity reactions
Knut Brockow, Gerda Wurpts, Axel Trautmann, Wolfgang Pfützner, Regina Treudler, Andreas J. Bircher, Randolf Brehler, Timo Buhl, Heinrich Dickel, Thomas Fuchs, Thilo Jakob, Julia Kurz, Burkhard Kreft, Lars Lange, Hans F. Merk, Maja Mockenhaupt, Norbert Mülleneisen, Hagen Ott, Johannes Ring, Franziska Ruëff, Bernhardt Sachs, Helmut Sitter, Bettina Wedi, Stefan Wöhrl, Margitta Worm, and Torsten Zuberbier
Volume 7 (2023) p. 122 - 139
Abstract
Allergologie select, Vol. 7/2023 (122-139)
Guideline for allergological diagnosis of drug hypersensitivity reactions
Knut Brockow1, Gerda Wurpts2, Axel Trautmann3, Wolfgang Pfützner4, Regina Treudler5, Andreas J. Bircher6, Randolf Brehler7, Timo Buhl8, Heinrich Dickel9, Thomas Fuchs8, Thilo Jakob10, Julia Kurz4, Burkhard Kreft11, Lars Lange12, Hans F. Merk2, Maja Mockenhaupt13, Norbert Mülleneisen14, Hagen Ott15, Johannes Ring1, Franziska Ruëff16, Bernhardt Sachs2, Helmut Sitter17, Bettina Wedi18, Stefan Wöhrl19, Margitta Worm20, and Torsten Zuberbier20
1Department of Dermatology and Allergology Biederstein, Faculty of Medicine, Technical University of Munich, Munich, 2Department of Dermatology and Allergology, Germany, Aachen Comprehensive Allergy Center (ACAC), University Hospital of RWTH Aachen University, Aachen, 3Department of Dermatology and Allergology, Allergy Center Mainfranken, University Hospital Würzburg, Würzburg, 4Department of Dermatology and Allergology, University Hospital Giessen and Marburg, Marburg, 5Department of Dermatology, Venerology and Allergology, University of Leipzig, Leipzig, Germany, 6Facoltà di Scienze biomediche, Università della Svizzera italiana, Lugano, and Department of Dermatology and Allergology, University Hospital Basel, Switzerland, 7Department of Dermatology, Münster University Hospital, Münster, 8Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Göttingen, 9Department of Dermatology, Venerology and Allergology, St. Josef Hospital, University Hospital of the Ruhr University Bochum, Bochum, 10Department of Dermatology and Allergology, University Hospital, Justus-Liebig University, Gießen, 11Department of Dermatology and Venereology, University Hospital Halle, Halle (Saale), 12Pediatric Clinic, Marienhospital Bonn, Bonn, 13Documentation Center for Severe Skin Reactions, Department of Dermatology and Venereology, University Medical Center Freiburg, Freiburg, 14Asthma Allergy Center Leverkusen, Leverkusen, 15Children’s and Youth Hospital Auf der Bult, Hanover, 16Department of Dermatology and Allergology, Allergy Center, Ludwig Maximilian University of Munich, 17Institute for Theoretical Surgery, Philipps University of Marburg, Marburg, 18Hanover Medical School, Department of Dermatology, Allergology and Venereology, Hanover, Germany, 19Floridsdorf Allergy Center (FAZ), Vienna, Austria, and 20Allergology and Immunology, Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, Berlin, Germany
Correspondence to:
Prof. Dr. med. Knut Brockow, Department of Dermatology and Allergology at Biederstein, Faculty of Medicine, Technical University of Munich, Biedersteiner Straße 29, 80802 Munich, Germany
Email: [email protected]
Guideline
Diagnosis and treatment of Hymenoptera venom allergy
Franziska Ruëff, Andrea Bauer, Sven Becker, Randolf Brehler, Knut Brockow, Adam M. Chaker, Ulf Darsow, Jörg Fischer, Thomas Fuchs, Michael Gerstlauer, Sunhild Gernert, Eckard Hamelmann, Wolfram Hötzenecker, Ludger Klimek, Lars Lange, Hans Merk, Norbert K. Mülleneisen, Irena Neustädter, Wolfgang Pfützner, Wolfgang Sieber, Helmut Sitter, Christoph Skudlik, Regina Treudler, Bettina Wedi, Stefan Wöhrl, Margitta Worm and Thilo Jakob
Volume 7 (2023) p. 154 - 190
Abstract
Allergologie select, Vol. 7/2023 (154-190)
Diagnosis and treatment of Hymenoptera venom allergy
Franziska Ruëff1, Andrea Bauer2, Sven Becker3, Randolf Brehler4, Knut Brockow5, Adam M. Chaker6, Ulf Darsow5, Jörg Fischer7, Thomas Fuchs8, Michael Gerstlauer9, Sunhild Gernert10, Eckard Hamelmann11, Wolfram Hötzenecker12, Ludger Klimek13, Lars Lange10, Hans Merk14, Norbert K. Mülleneisen15, Irena Neustädter16, Wolfgang Pfützner17, Wolfgang Sieber18, Helmut Sitter19, Christoph Skudlik20, Regina Treudler21, Bettina Wedi22, Stefan Wöhrl23, Margitta Worm24 and Thilo Jakob25
1Department of Dermatology and Allergy, LMU University Hospital, Munich, 2Department of Dermatology, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, 3Department of Otorhinolaryngology, Head and Neck Surgery, University of Tuebingen, Tübingen, 4Department of Dermatology, Münster University Hospital, Münster, 5Department of Dermatology and Allergology Biederstein, Faculty of Medicine, Technical University of Munich, Munich, 6Department of Otorhinolaryngology Klinikum rechts der Isar, Faculty of Medicine, Technical University of Munich, Munich, 7University Hospital for Dermatology and Allergology, Clinic Oldenburg, Oldenburg, 8Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Göttingen, 9Clinic for Children and Adolescents, University Hospital Augsburg, Augsburg, 10Pediatric Clinic, Marienhospital Bonn, GFO Kliniken, Bonn, 11Children’s Center Bethel, University Hospital OWL, Bielefeld University, Bielefeld, Germany, 12Department of Dermatology, Kepler University Hospital, Medical Faculty of University Linz, Linz, Austria, 13Center for Rhinology and Allergology, Wiesbaden, 14Department of Dermatology and Allergology, University Hospital of RWTH Aachen University, Aachen, 15Center for Asthma and Allergy, Leverkusen, 16Cnopfsche Paediatric Clinic, Nuremberg, 17Department of Dermatology and Allergology, University Hospital Marburg, Philipps-Universität Marburg, Marburg, 18Hospital Wörth an der Donau, Wörth an der Donau, 19Institute for Theoretical Surgery, Philipps-University Marburg, Marburg, 20Institute for Interdisciplinary Dermatological Prevention and Rehabilitation (iDerm) at the University of Osnabrueck, Osnabrueck, and BG Clinic Hamburg, Hamburg, 21University Leipzig Medical Faculty, Leipzig, 22Comprehensive Allergy, Department of Dermatology and Allergy, Hannover Medical School, Hanover, Germany, 23Floridsdorf Allergy Center (FAZ), Vienna, Austria, 24Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Berlin, and 25Department of Dermatology and Allergology, University Hospital Giessen, Justus Liebig University Gießen, Gießen, Germany
Hymenoptera venom (HV) is injected into the skin during a sting by Hymenoptera such as bees or wasps. Some components of HV are potential allergens and can cause large local and/or systemic allergic reactions (SAR) in sensitized individuals. During their lifetime, ~ 3% of the general population will develop SAR following a Hymenoptera sting. This guideline presents the diagnostic and therapeutic approach to SAR following Hymenoptera stings. Symptomatic therapy is usually required after a severe local reaction, but specific diagnosis or allergen immunotherapy (AIT) with HV (VIT) is not necessary. When taking a patient’s medical history after SAR, clinicians should discuss possible risk factors for more frequent stings and more severe anaphylactic reactions. The most important risk factors for more severe SAR are mast cell disease and, especially in children, uncontrolled asthma. Therefore, if the SAR extends beyond the skin (according to the Ring and Messmer classification: grade > I), the baseline serum tryptase concentration shall be measured and the skin shall be examined for possible mastocytosis. The medical history should also include questions specific to asthma symptoms. To demonstrate sensitization to HV, allergists shall determine concentrations of specific IgE antibodies (sIgE) to bee and/or vespid venoms, their constituents and other venoms as appropriate. If the results are negative less than 2 weeks after the sting, the tests shall be repeated (at least 4 – 6 weeks after the sting). If only sIgE to the total venom extracts have been determined, if there is double sensitization, or if the results are implausible, allergists shall determine sIgE to the different venom components. Skin testing may be omitted if in-vitro methods have provided a definitive diagnosis. If neither laboratory diagnosis nor skin testing has led to conclusive results, additional cellular testing can be performed. Therapy for HV allergy includes prophylaxis of reexposure, patient self treatment measures (including use of rescue medication) in the event of re-stings, and VIT. Following a grade I SAR and in the absence of other risk factors for repeated sting exposure or more severe anaphylaxis, it is not necessary to prescribe an adrenaline auto-injector (AAI) or to administer VIT. Under certain conditions, VIT can be administered even in the presence of previous grade I anaphylaxis, e.g., if there are additional risk factors or if quality of life would be reduced without VIT. Physicians should be aware of the contraindications to VIT, although they can be overridden in justified individual cases after weighing benefits and risks. The use of β-blockers and ACE inhibitors is not a contraindication to VIT. Patients should be informed about possible interactions. For VIT, the venom extract shall be used that, according to the patient’s history and the results of the allergy diagnostics, was the trigger of the disease. If, in the case of double sensitization and an unclear history regarding the trigger, it is not possible to determine the culprit venom even with additional diagnostic procedures, VIT shall be performed with both venom extracts. The standard maintenance dose of VIT is 100 µg HV. In adult patients with bee venom allergy and an increased risk of sting exposure or particularly severe anaphylaxis, a maintenance dose of 200 µg can be considered from the start of VIT. Administration of a non-sedating H1-blocking antihistamine can be considered to reduce side effects. The maintenance dose should be given at 4-weekly intervals during the first year and, following the manufacturer’s instructions, every 5 – 6 weeks from the second year, depending on the preparation used; if a depot preparation is used, the interval can be extended to 8 weeks from the third year onwards. If significant recurrent systemic reactions occur during VIT, clinicians shall identify and as possible eliminate co-factors that promote these reactions. If this is not possible or if there are no such co-factors, if prophylactic administration of an H1-blocking antihistamine is not effective, and if a higher dose of VIT has not led to tolerability of VIT, physicians should should consider additional treatment with an anti IgE antibody such as omalizumab as off lable use. For practical reasons, only a small number of patients are able to undergo sting challenge tests to check the success of the therapy, which requires in-hospital monitoring and emergency standby. To perform such a provocation test, patients must have tolerated VIT at the planned maintenance dose. In the event of treatment failure while on treatment with an ACE inhibitor, physicians should consider discontinuing the ACE inhibitor. In the absence of tolerance induction, physicians shall increase the maintenance dose (200 µg to a maximum of 400 µg in adults, maximum of 200 µg HV in children). If increasing the maintenance dose does not provide adequate protection and there are risk factors for a severe anaphylactic reaction, physicians should consider a co-medication based on an anti-IgE antibody (omalizumab; off-label use) during the insect flight season. In patients without specific risk factors, VIT can be discontinued after 3 – 5 years if maintenance therapy has been tolerated without recurrent anaphylactic events. Prolonged or permanent VIT can be considered in patients with mastocytosis, a history of cardiovascular or respiratory arrest due to Hymenoptera sting (severity grade IV), or other specific constellations associated with an increased individual risk of recurrent and/or severe SAR (e.g., hereditary α-tryptasemia). In cases of strongly increased, unavoidable insect exposure, adults may receive VIT until the end of intense contact. The prescription of an AAI can be omitted in patients with a history of SAR grade I and II when the maintenance dose of VIT has been reached and tolerated, provided that there are no additional risk factors. The same holds true once the VIT has been terminated after the regular treatment period. Patients with a history of SAR grade ≥ III reaction, or grade II reaction combined with additional factors that increase the risk of non response or repeated severe sting reactions, should carry an emergency kit, including an AAI, during VIT and after regular termination of the VIT.Correspondence to:
Prof. Dr. med. Franziska Ruëff, Klinik und Poliklinik für Dermatologie, und Allergologie, Klinikum der Universität München, Frauenlobstraße 9-11, 80337 Munich, Germany,
Email: [email protected]
Consensus paper
“Delabeling” by direct provocation testing in children and adolescents with a suspected history of a delayed reaction to β-lactam antibiotics. Consensus paper of Gesellschaft für pädiatrische Allergologie und Umweltmedizin (GPAU
Irena Neustädter, Sophie Blatt, Gerda Wurpts, Heinrich Dickel, Christian Walter, Werner Aberer, Sebastian Bode, Timo Buhl, Sunhild Gernert, Susanne Harner, Guido Heine, Sebastian Kerzel, Meike Köhler, Lars Lange, Joachim List, Hans F. Merk, Thomas Nüßlein, Hagen Ott, Franziska Sattler, Antje Schuster, Helen Straube, Bettina Wedi, Torsten Zuberbier, and Knut Brockow
Volume 8 (2024) p. 206 - 211
Abstract
Allergologie select, Vol. 8/2024 (206-211)
“Delabeling” by direct provocation testing in children and adolescents with a suspected history of a delayed reaction to β-lactam antibiotics. Consensus paper of Gesellschaft für pädiatrische Allergologie und Umweltmedizin (GPAU
Irena Neustädter1, Sophie Blatt1, Gerda Wurpts3, Heinrich Dickel4, Christian Walter5, Werner Aberer6, Sebastian Bode7, Timo Buhl8, Sunhild Gernert9, Susanne Harner10, Guido Heine11, Sebastian Kerzel10, Meike Köhler12, Lars Lange9, Joachim List13, Hans F. Merk2, Thomas Nüßlein14, Hagen Ott15, Franziska Sattler12, Antje Schuster16, Helen Straube17, Bettina Wedi18, Torsten Zuberbier19, and Knut Brockow2
1Pediatric and Adolescent Medicine, Diakoneo Klinik Hallerwiese-Cnopfsche Kinderklinik, Nuremberg, 2Clinic and Polyclinic for Dermatology and Allergology at Biederstein, Technical University of Munich, Munich, 3Clinic for Dermatology and Allergology, Aachen Comprehensive Allergy Center (ACAC), University Hospital of RWTH Aachen University, Aachen, 4Clinic for Dermatology, Venereology and Allergology, St. Josef Hospital, University Hospital of the Ruhr University Bochum, Bochum, 5Practice for Pediatric and Adolescent Medicine, Allergology, Bad Homburg, Germany, 6Department of Dermatology and Venereology, Medical University of Graz, Austria, 7University Clinic for Children and Adolescents, Ulm, 8Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, 9Department of Pediatrics, St. Marien Hospital, GFO Clinics, Bonn, 10Clinic and Polyclinic for Pediatrics and Adolescent Medicine, University of Regensburg, Regensburg, 11Department of Dermatology, Venereology and Allergology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, 12Asthma and Allergy Outpatient Clinic, Dr. von Hauner Children’s Hospital, LMU University Hospital, Munich, 13University of Freiburg, Center for Pediatric and Adolescent Medicine, Freiburg, 14Clinic for Pediatrics and Adolescent Medicine, Gemeinschaftsklinikum Mittelrhein, Koblenz, 15Children’s and Youth Hospital Auf der Bult, Hanover, 16Clinic for General Pediatrics, Neonatology and Pediatric Cardiology, University Hospital Düsseldorf, Düsseldorf, 17Princess Margaret Children’s Hospital, Darmstadt, 18Hannover Medical School, Clinic for Dermatology, Allergology and Venereology, Hanover, and 19Allergology and Immunology, Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, Berlin, Germany
Background: Approximately 10% of European children are classified as allergic to drugs. In the majority of these children, no allergy to β-lactam antibiotics (BLA) can be found. In most cases, the exanthema is caused by the infection. Materials and methods: The objective of this paper is to describe the causes and consequences of a misdiagnosis of drug allergy. We propose a method for establishing a correct diagnosis in the case of a history of a delayed reaction during treatment with a BLA. For this purpose, a proposal was discussed via e-mail communication, and consensus was reached among the members of the drug allergy working groups of the participating medical societies. Results: The suspicion of a BLA allergy based on the medical history alone can have a negative impact on future antibiotic treatment. Exanthema associated with febrile infections not related to drug administration is a frequent finding in children. This makes it all the more important to be able to recommend a standardized procedure for clarification in children and adolescents with suspected hypersensitivity reactions. The medical history should be the basis on which to diagnose either a drug allergy or another possible differential diagnosis. A mild maculopapular exanthema (MPE) can be an expression of a drug allergy or a nonspecific viral exanthema. Uncomplicated MPE is not associated with significant systemic involvement, and there is no involvement of the mucous membranes or cutaneous blistering. Only a small number of children with uncomplicated MPE show positive skin tests and only ~ 7 – 16% of suspected BLA diagnoses can be confirmed by provocation tests. Thus, in children with uncomplicated MPE, drug provocation can be performed in an outpatient setting even without prior skin testing. This paper presents a 3-day outpatient direct provocation scheme for BLA delabeling in children with uncomplicated MPE. Conclusion: Many children and adolescents are unnecessarily denied treatment with BLA after an uncomplicated MPE while being treated with a BLA.Correspondence to:
Dr. med. Irena Neustädter, Pediatric and Adolescent Medicine, Diakoneo Klinik Hallerwiese-Cnopfsche Kinderklinik, St.-Johannis-Mühlgasse 19, 90419 Nuremberg, Germany
Email: [email protected]
Review
Adrenaline nasal spray in emergency management: An initial expert opinion
Regina Treudler, Knut Brockow, Kirsten Beyer, Ludger Klimek, Lars Lange, Sabine Schnadt, Johannes Ring, and Margitta Worm
Volume 9 (2025) p. 80 - 85
Abstract
Allergologie select, Vol. 9/2025 (80-85)
Adrenaline nasal spray in emergency management: An initial expert opinion
Regina Treudler1, Knut Brockow2, Kirsten Beyer3,4, Ludger Klimek5, Lars Lange6, Sabine Schnadt7, Johannes Ring2, and Margitta Worm8
1Institute of Allergology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, 2Department of Dermatology and Allergology am Biederstein, Faculty of Medicine and Health, Technical University of Munich, Munich, 3Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, 4German Center for Child and Adolescent Health (DZKJ), Berlin, 5Center for Rhinology and Allergology, Wiesbaden, 6Department of Pediatrics and Adolescent Medicine, St. Marien-Hospital, Bonn, 7German Allergy and Asthma Association (DAAB). (DAAB), Mönchengladbach, and 8Department of Dermatology, Venerology and Allergology, Charité – Universitätsmedizin Berlin, Berlin, Germany
Adrenaline is the drug of choice for the treatment of anaphylaxis. Up to now, intramuscular administration using an autoinjector has been recommended in national and international guidelines as the first-line treatment for anaphylaxis. Various adrenaline autoinjectors are available on the German market as emergency medication for immediate treatment by medical laypersons and specialists. Recently, a nasally administered adrenaline preparation was introduced for the first time and is available on the market. There are mainly data on healthy control subjects, which show a good adrenaline level and an expected effect on blood pressure and heart rate. To date, there is little clinical experience in the world literature for patients with anaphylaxis in children/adolescents and none in adults or from Germany. Therefore, we would like to discuss theoretically the use of adrenaline via the nasal route of administration in the care of anaphylaxis patients and compare it with the intramuscular administration of adrenaline autoinjectors.Correspondence to:
Prof. Dr. med. Regina Treudler, Institute of Allergology, Charité – Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
Email: [email protected]
Guideline
S2k-Guideline – Standardized application of the nasal and conjunctival provocation test on allergic diseases of the upper airways
Ulrike Förster-Ruhrmann, Tobias Ankermann, Sven Becker, Petra Bubel, Mandy Cuevas, Moritz Gröger, Ludger Klimek, Lars Lange, Katrin Milger, Philip Maier, Norbert Muelleneisen, Dennis Nowak, Heidi Olze, Uwe Pleyer, Wolfgang Schlenter, Sebastian Schmidt, Antje Schuster, Martin Wagenmann, Bettina Wedi, and Oliver Pfaar
Volume 10 (2026) p. 234 - 258
Abstract
Allergologie select, Vol. 10/2026 (234-258)
S2k-Guideline – Standardized application of the nasal and conjunctival provocation test on allergic diseases of the upper airways
Ulrike Förster-Ruhrmann1, Tobias Ankermann2, Sven Becker3, Petra Bubel4, Mandy Cuevas5, Moritz Gröger6,7, Ludger Klimek8, Lars Lange9, Katrin Milger10,11, Philip Maier12, Norbert Muelleneisen13, Dennis Nowak14, Heidi Olze1, Uwe Pleyer15, Wolfgang Schlenter16, Sebastian Schmidt17, Antje Schuster18, Martin Wagenmann19, Bettina Wedi20, and Oliver Pfaar21
1Department of Otorhinolaryngology, CCM and CVK, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charité - Universitätsmedizin Berlin, Berlin, 2Childrens Hospital, Städtisches Krankenhaus Kiel gGmbH, Kiel, 3Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Center, Tübingen, 4ENT practice Dr. Bubel, Eisleben, 5Faculty of Medicine and University Hospital Carl Gustav Carus, Department of Otorhinolaryngology Head and Neck Surgery, TUD Dresden University of Technology, Dresden, 6Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Ludwig Maximilian University of Munich, Munich, 7HNO am Maximiliansplatz, Munich, 8Center for Rhinology and Allergology, Wiesbaden, 9Department of Pediatrics, GFO-Kliniken Bonn, St. Marien-Hospital, Bonn, 10Department of Medicine V, University Hospital of the Ludwig Maximilian University Munich, Munich, Germany, 11Division of Respiratory Medicine, Department of Internal Medicine, Medical University of Graz, Austria, 12Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, 13Asthma-Allergiezentrum, Leverkusen, 14Institute and Clinic for Occupational, Social and Environmental Medicine, CPC (Comprehensive Pneumology Center) Munich, DZL, German Center for Lung Research, Munich, 15Department of Ophthalmology, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt- Universität zu Berlin, Berlin, 16Langenselbold, 17Department of Pediatrics, University Medicine, Greifswald, 18Center for Paediatric and Adolescent Medicine, University Medical Center, Düsseldorf, 19Department of Otorhinolaryngology, Düsseldorf University Hospital (UKD), Düsseldorf, 20Department of Dermatology and Allergy, Comprehensive Allergy Center, Hanover Medical School, Hannover, and 21Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany
Broad evidence confirms that AR (ICD J30.3) is a chronic disease with high prevalence among children and adults worldwide. Its consequences, both from a public health perspective and at the level of the individual patient, are often underestimated, and the condition is inadequately treated. In addition, AR is often related to comorbidities with additional impact on diseases-severity. Allergen provocation of the easily accessible nasal (nasal allergen provocation test: NPT) or conjunctival mucosa (conjunctival allergen provocation test: CPT) reproduces the allergen-dependent, IgE-mediated allergic reaction under controlled and standardized conditions. These measures are regarded as the diagnostic gold standard, particularly in cases of unclear results in primary allergological tests, enabling clinically relevant identification of the causative allergen. Approved test allergens are critical for ensuring the methodological quality of the NPT. However, their availability is increasingly limited, although adequate quantities of allergen solutions remain indispensable for high-quality nasal allergen testing. Unilateral allergen provocation has been established in the clinical routine for decades in Germany. However, scientific evidence for unilateral application of the test allergen is pending. International position papers differ from this recommendation. The CPT is a simple, safe, and well-tolerated measure. It is primarily used in perennial and, in selected cases, seasonal allergic conjunctivitis. This method is less commonly applied for vernal keratoconjunctivitis and atopic keratoconjunctivitis. It is primarily used to confirm the underlying allergen, particularly when establishing the indication for allergen immunotherapy (AIT). It can also be employed to monitor treatment effects such as e.g., AIT or pharmacotherapy. Although highly sensitive, the procedure of nasal ASA provocation remains a time-consuming procedure. While challenging in children, NPT provides clinically relevant additional diagnostic information on the causes of the allergic symptoms. Allergological diagnostic work-up also includes pulmonary assessment, particularly in patients with established asthma or symptoms suggestive of asthma. Both AAR and PNIF are applied as standard procedures for assessing the outcome of NPT in Germany. In individual cases, other rhinometric methods may also be used.Correspondence to:
Dr. Ulrike Förster-Ruhrmann, Department of Otorhinolaryngology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany, And Prof. Dr. Oliver Pfaar, Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, University Hospital Marburg, Philipps-Universität Marburg, Baldingerstrasse, 35043 Marburg, Germany
Email: [email protected]
Position Paper
Artificial intelligence in allergology: A Position Paper of the German Society of Allergology and Clinical Immunology (DGAKI), Ärzteverband Deutscher Allergologen (AeDA) and German Society of Pediatric Allergology and Environmental Medicine (GPA): P1
Oliver Pfaar, Stephan Traidl, Friederike Bärhold, Sven Becker, Christoph Bergmann, Jeroen Buters, Stephanie Dramburg, Wojciech Francuzik, Michael Gerstlauer, Eckard Hamelmann, Camilo José Hernandez Toro, Ludger Klimek, Lars Lange, Paolo M. Matricardi, Laura Pfeffer, Mariel Suarez-Suarez, Philipp Utz, Martin Wagenmann, Margitta Worm, Mehrak Yoosefi, Sonja Mathes, and Sebastian Seurig
Volume 10 (2026) p. 303 - 322
Abstract
Allergologie select, Vol. 10/2026 (303-322)
Artificial intelligence in allergology: A Position Paper of the German Society of Allergology and Clinical Immunology (DGAKI), Ärzteverband Deutscher Allergologen (AeDA) and German Society of Pediatric Allergology and Environmental Medicine (GPA): P1
Oliver Pfaar1, Stephan Traidl2, Friederike Bärhold3, Sven Becker4, Christoph Bergmann5, Jeroen Buters6, Stephanie Dramburg7, Wojciech Francuzik8, Michael Gerstlauer9, Eckard Hamelmann10, Camilo José Hernandez Toro7,11, Ludger Klimek3, Lars Lange12, Paolo M. Matricardi7,13,14, Laura Pfeffer15, Mariel Suarez-Suarez6, Philipp Utz16, Martin Wagenmann17, Margitta Worm8, Mehrak Yoosefi18, Sonja Mathes19, and Sebastian Seurig20
1Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, University Hospital Marburg, Philipps-Universität Marburg, Marburg, 2Department of Dermatology and Allergy, Medizinische Hochschule Hannover, Hanover, 3Center for Rhinology and Allergology, Wiesbaden, 4Department of Otorhinolaryngology, Head and Neck Surgery, University of Tübingen, 5Hals-Nasen-Ohrenheilkunde, interdisziplinäre Facharztklinik, Düsseldorf, 6Center of Allergy & Environment (ZAUM), Member of the German Center for Lung Research (DZL), Technical University and Helmholtz Center, Munich, 7Department of Pediatric Respiratory Care, Immunology and Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, 8Allergology and Immunology, Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin, Berlin, 9Pediatric Pulmonology and Allergology, University Hospital Augsburg, Augsburg, 10Children‘s Center Bethel, University Hospital OWL, University Bielefeld, Bielefeld, 11Institute of Biometry and Clinical Epidemiology, Charité – Universitätsmedizin Berlin, Berlin, 12Department of Pediatrics, GFO-Kliniken Bonn, St. Marien-Hospital, Bonn, 13Institute of Allergology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 14Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, 15Pediatric Dermatology and Allergology, Kinder- und Jugendkrankenhaus AUF DER BULT, Hannover, 16Kinderarztpraxis Hirschberg, Hirschberg, 17Department of Otorhinolaryngology, Düsseldorf University Hospital, Düsseldorf, 18Kinderarztpraxis Dr. med. Mehrak Yoosefi, Berlin, 19Department of Dermatology and Allergology, TUM Clinic Rechts der Isar, School of Medicine and Health, Technical University of Munich, Munich, and 20Department of Respiratory Medicine, Allergology and Sleep Medicine, General Hospital Nuremberg, Campus North, Paracelsus Medical University, Nuremberg, Germany
Background: Artificial intelligence (AI) is rapidly advancing in medicine, yet its translation into clinical and research practice in allergology remains limited. Given the heterogeneity of allergic diseases and the complexity of integrating clinical, environmental, and molecular data, a structured assessment is required. This first part of a joint position paper, developed by German allergology societies and associations under the leadership of the DGAKI, aims to establish a conceptual and clinical foundation for AI in allergology. Materials and methods: The Position Paper is based on a targeted narrative literature review and structured expert consensus. Development was informed by AGREE II principles. Part I comprises Chapters 1 – 4, covering introduction, methodology, AI taxonomy, and selected early application domains. Results: AI is conceptualized as an augmentative tool supporting clinical reasoning and individualized decision-making. The paper distinguishes classical statistical approaches from machine learning, deep learning, vision models, and large language models, emphasizing their complementary roles. Key applications include environmental analytics (e.g., automated pollen monitoring and forecasting), image-based classification systems, clinical decision support for diagnostics and therapy, and emerging patient-facing tools. Across these domains, AI may improve diagnostic precision and enable integration of heterogeneous data. Limitations include restricted generalizability, bias, limited explainability, and regulatory and data protection challenges. Conclusion: The role of AI in allergology is defined, its methodological basis is outlined, and initial application domains are highlighted. Together, these elements provide a framework for evidence-based and patient-oriented integration, requiring human oversight, robust scientific validation, and regulatory alignment.Correspondence to:
Prof. Dr. Oliver Pfaar, Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, University Hospital Marburg, Philipps-Universität Marburg, Germany, or Dr. med. Sonja Mathes, Department of Dermatology and Allergology, TUM Clinic Rechts der Isar, School of Medicine and Health, Technical University of Munich, Munich, Germany
Email: [email protected]
