AAAAI Releases Second List of Tests and Procedures That Are Overused to Diagnose and Treat Allergies, Asthma and Immunologic Diseases

As part of the Choosing Wisely® campaign, AAAAI identifies five more tests or procedures physicians and patients should question and discuss.

San Diego, CA – The American Academy of Allergy, Asthma & Immunology (AAAAI) today released a list of “Five More Things Physician and Patients Should Question” as part of the ABIM Foundation’s Choosing Wisely initiative. This list focuses on and explains specific tests or procedures that are overused in the diagnosis and treatment of allergies.

“The AAAAI’s second Choosing Wisely list will further facilitate wise healthcare choices in the diagnosis and treatment of allergies, asthma and immunologic diseases,” said AAAAI President Linda Cox, MD, FAAAAI. “It identifies five more evidence-based recommendations that will support conversations between patients and physicians about what care is appropriate and necessary.”

The following are the five recommendations, along with excerpts from their explanations, which appear on the AAAAI’s latest list:

Don’t rely on antihistamines as first line treatment in severe allergic reactions.

Epinephrine is the first-line treatment for anaphylaxis. Data indicate that antihistamines are overused as the first-line treatment of anaphylaxis. By definition, anaphylaxis has cardiovascular and respiratory manifestations, which require treatment with epinephrine. Overuse of antihistamines, which do not treat cardiovascular or respiratory manifestations of anaphylaxis, can delay the effective first-line treatment with epinephrine.

Don’t perform food IgE testing without a history consistent with potential IgE-mediated food allergy.    

False or clinically irrelevant positive allergy tests for foods are frequent. Indiscriminate screening results in inappropriate avoidance of foods and wastes healthcare resources. IgE testing for specific foods must be driven by a history of signs or symptoms consistent with an IgE-mediated reaction after eating a particular food. Ordering IgE testing in individuals who do not have a history consistent with or suggestive for food allergy based on history frequently reveals positive tests that are unlikely to be clinically relevant. Testing, when done, should be limited to suspected foods.

Don’t routinely order low- or iso-osmolar radiocontrast media or pretreat with corticosteroids and antihistamines for patients with a history of seafood allergy, who require radiocontrast media.

Although the exact mechanism for contrast media reactions is unknown, there is no cause and effect connection with seafood allergy. Consequently there is no reason to use more expensive agents or pre-medication before using contrast media in patients with a history of seafood allergy. A prior history of anaphylaxis to contrast media is an indication to use low- or iso-osmolar agents and pretreat with corticosteroids and antihistamines.

Don’t routinely avoid influenza vaccination in egg-allergic patients.

Of the vaccines that may contain egg protein (measles, mumps, rabies, influenza and yellow fever), measles, mumps and rabies vaccines have at most negligible egg protein; consequently no special precautions need to be followed in egg-allergic patients for these vaccines. Studies in egg-allergic patients receiving egg-based inactivated influenza vaccine have not reported reactions; consequently egg-allergic patients should be given either egg-free influenza vaccine or should receive egg-based influenza vaccine with a 30-minute post-vaccine observation period. Egg-allergic patients receiving the yellow fever vaccine should be skin tested with the vaccine and receive the vaccine with a 30-minute observation period if the skin test is negative. If positive, the vaccine may be given in graded doses with appropriate medical observation.

Don’t overuse non-beta lactam antibiotics in patients with a history of penicillin allergy, without an appropriate evaluation.

While about 10 percent of the population reports a history of penicillin allergy, studies show that 90 percent on more of these patients are not allergic to penicillins and are able to take these antibiotics safely. The main reason for this observation is that penicillin allergy is often misdiagnosed and when present wanes over time in most (but not all) individuals. Patients labeled penicillin-allergic are more likely to be treated with alternative antibiotics (such as vancomycin and quinolones), have higher medical costs, experience longer hospital stays, and are more likely to develop complications such as infections with vancomycin-resistant enterococcus (VRE) and Clostridium difficile.

As with its first list, the second AAAAI Choosing Wisely list was developed after months of careful consideration and review, using the most current evidence about management and treatment options.

To learn more about Choosing Wisely and to view the complete lists and additional detail about the recommendations and evidence supporting them, visit

About AAAAI: The AAAAI represents allergists, asthma specialists, clinical immunologists, allied health professionals and others with a special interest in the research and treatment of allergic disease. Established in 1943, the AAAAI has more than 6,700 members in the United States, Canada and 60 other countries. The AAAAI’s Find an Allergist/Immunologist service is a trusted resource to help you find a specialist close to home.

Contact: Megan Brown
(414) 272-6071