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New tests and drug treatments on the horizon.
Allergies affect more than 50 million people in the United States and cost about $7 billion annually. Although experts say that the key to cutting costs is testing prior to treating, new treatments scheduled to hit the market in the next year will also cut costs and improve quality of care.
Allergic rhinitis, or hay fever, is the most common chronic allergy. Not only does it cause allergy symptoms such as a running rose, sneezing, nasal congestion and coughing, but inflammation and narrowing of the airways can also reduce airflow to the lungs, causing shortness of breath and wheezing-symptoms of asthma.
“Chronic allergies often mean a patient has asthma, which can be very severe,” says Richard Honsinger, MD, president of the Joint Council of Allergy, Asthma and Immunology (JCAAI).
Asthma is one of the top five chronic diseases in the United States and costs the healthcare industry an estimated $56 billion annually. The most common allergens enter through the airways, and about 80% of asthmatics in the have underlying allergies.
Although about 90% of children have one or more allergic triggers for their asthma, and about 50% to 60% of adult asthmatics have one or more allergic triggers, only 5% to 10% of asthma patients are reportedly tested for allergies.
“Addressing allergic components for allergic asthmatics is the key to improving their outcomes,” says Robert Reinhardt, MD, associate professor of family medicine at Michigan State University and US medical director of ImmunoDiagnostics at Thermo Fisher Scientific, a precision laboratory company. “To optimally control a patient’s condition, you need to know whether allergic triggers are involved, what those triggers are so you can intervene in a meaningful way and know the relative importance those triggers have if a patient has multiple.”
Experts say that one of the best ways to diagnose allergies is to simply talk with a patient and create an allergy profile. However, with millions of newly insured patients increasing demand on the system, physicians may not have the extra time.
“Physicians need to take time with their patients, but they’re more compelled to move on to the next one and see so many patients in a day,” Dr. Honsinger says. “We’re starting to see propriety agencies put technicians in offices to do allergy tests for family doctors. Those folks are not going to have the experience of a physician: reviewing the patient, reviewing their history and ferretting out the problem.”
For some patients, their allergens are fairly obvious-like pet dander, for example-but other triggers can be more challenging to determine. Rather than guessing blindly, it’s more cost efficient to target treatment efforts after confirming sensitivity through testing.
“Very often we see objectives by clinicians to help patients reduce exposure to allergic triggers in the environment, but the steps [for testing] are skipped,” Dr. Reinhardt says. “Without testing, the whole approach doesn’t work and won’t work unless you know what a patient is actually sensitized to.”
Dr. Honsinger says the best method to determine allergies is to perform a traditional skin-prick test.
“Blood tests aren’t as effective as skin tests because the allergic antibody is preferentially bound to cells,” he says. “What’s floating around in the blood isn’t always accurate.”
However, newer technology for blood testing has advanced in recent years. According to Dr. Reinhardt, allergen-specific Immunoglobulin E (IgE) blood testing can determine whether the patient has allergic asthma, non-allergic asthma or other allergies; specific triggers; and a ranking of importance for multiple triggers. This is helpful when determining how to intervene.
Other advantages to IgE test are that patients can continue to take daily medications. Patients already coping with symptoms don’t have to experience an exacerbation of their symptoms by stopping their current treatment, which is requirement for a skin-prick test.
Allergy experts say plans need to make sure that they include testing as part of their programs for allergic and asthmatic patients. Information obtained from testing can be used to better control the patient’s allergies and asthma and also decrease a plan’s expenditures.
“The tendency is to look at testing as an additional cost, but instead it should be looked at in the context of total care of the patient-in terms of selecting the proper treatments, impacting the number of unscheduled doctor’s office visits or decreasing the number of emergency room visits and hospitalizations,” Dr. Reinhardt says. “Plans want to improve outcomes, and they want to reduce costs. There’s evidence that the testing component as part of the overall care of a patient is helpful in both regards.”
To ensure compliance with identifying allergy triggers prior to treatment, Dr. Renhardt says plans are implementing internal measures. For example, using EMRs to alert physicians prescribing asthma- and allergy-targeted medications to wait until testing is completed.
Reducing exposure to allergens is the first step in treating allergies. Two common ways to address allergies are immunotherapy, or allergy shots, and medications like antihistamines. Dr. Honsinger says antihistamines are still the best method.
“They’ve gotten better-fewer side effects, a little less drowsiness-and are still a mainstay of allergy therapy,” he says. “And the good ones are now all over-the-counter.”
Although the effects of allergy shots can last up to 20 years, anaphylaxis is always a risk. Whoever administers the shot must be prepared to observe patients for 30 minutes after administering to ensure no reaction takes place. If symptoms persist, adding a cortisone nasal spray would come next.
“Some [nasal sprays] are generic now and will be going over-the-counter within the next couple of months,” Dr. Honsinger says. “Having over-the-counter antihistamines and over-the-counter nasal sprays will certainly make a difference for people.”
New sublingual and oral immunotherapy treatments that directly address allergic components are also soon to become available. Rather than a traditional allergy shot, allergy suffers can simply place it under their tongues. This makes it much easier to comply with treatment. Patients can treat themselves at home on a daily basis.
The treatment is expected to hit the market in time for the 2014 spring allergen season. Costs are higher than other immunotherapies, because a much higher dose of pollen extract is needed and it must be taken daily.
One advantage is that severe reactions are rare, Dr. Honsinger says, but it doesn’t work as well as the shots and takes longer to take effect. Meant for patients desensitized to a single allergen, specifically grass pollen, it won’t help patients suffering from multiple allergies.
For allergic asthma, an injection treatment of Xolair (omalizumab)-a monoclonal antibody treatment that targets IgE-has proven to be effective.
“Better monoclonal antibody, anti-IgE products are on the horizon,” Dr. Reinhardt says. “Hopefully more allergic asthmatics will be able to take advantage of that and it will bring costs down.”
Administered every two weeks to a month, depending on the patient’s blood level, omalizumab binds to the allergic antibody and blocks the patient’s allergic response. For some, the results have been dramatic.
“If we block this one particular factor we can improve the situation,” Dr. Honsinger says. “At least five other drugs like it are coming down the pipeline in the next two to three years.”
A single treatment might cost $1,000, but it has relative value compared to the price of recurring hospitalizations.
A 2008 study by Aetna found that self-identified African Americans and Hispanics use the emergency department three times as often for asthma incidents as Whites, amounting to avoidable costs estimated at $121,000 per 1,000 members.
“This overuse could be avoided with improvements in asthma care and better management of asthma,” says Wayne Rawlins, MD, national medical director, Aetna clinical thought leadership. “Such health advancements, with preventive care being central, would also drive reductions in medical costs.”
Dr. Honsinger says JCAAI is working with the National Committee for Quality Assurance and the Centers for Medicare and Medicaid Services to promote high-value coordinated care between physicians and allergy specialists.
“If clinicians didn’t do things twice, it wouldn’t cost as much,” he says. “As doctors [transition] to new computer systems, they will be able to communicate better. A lot of times you can avoid expense and may even avoid seeing the patient.”