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Question: I have a 69-year-old patient who developed a rash on her left arm and face lasting five weeks. This occurred two days after the Moderna RNA vaccine. She got the booster and in less than 24 hours had a more severe rash also on left arm and face lasting several months. When a third shot is available do I tell her to forego a second booster or get it with antihistamine pre-treatment or get a dose of the J&J vaccine?

Answer: These delayed onset benign rashes are thought to be secondary to T-cell activation. They often require no therapy, but if are itchy, treatment with a non-sedating antihistamine may be helpful. They may or may not recur with booster doses and there is no data on their frequency with three doses. If possible, avoid the use of systemic steroids, because this may blunt producing good anti-COVID-19 T-cell immunity. The use of another vaccine such as the J&J is a reasonable choice for a booster dose in this setting. However, there are no data to say that she won’t have a reaction to the J&J vaccine, as well (since this is a presumed T cell response).

  1. https://www.nejm.org/doi/full/10.1056/NEJMc2102131
  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8244618/

Question: A 49-year-old female who self-referred for flushing and possible food allergy or histamine intolerance. She was found to have a Tryptase of 20 and then 27 on repeat. Gene By gene testing revealed Alpha Tryptase of 4 and Beta Tryptase of 2. She has no Ckit mutation in the blood and has bone marrow biopsy report pending. Interestingly she also has some features of autoinflammation and genetic panel reviewed two variants: MEFV p.Lys695Arg and NOD2 p.Asp154Asn. I have referred her to autoinflammatory disease center for evaluation of this and this is also pending.

She is avidly against the COVID-19 vaccine and she is a pediatric nurse in the hospital. I am aware of other publications of patients with systemic mastocytosis who have been pre-medicated and given the vaccine. I am wondering how you would approach this in a patient with possible HAT and possible autoinflammatory disease. She had the following reaction to Tetanus vaccine: "Experienced severe swelling, redness, and increasing pain radiating to my whole upper left extremity between Day one and three after vaccination. The skin crusted into a weeping scabby area at the vaccine site. I became lethargic and febrile >104° so my husband took me to the ER three days after the vaccine where they administered Benadryl and IV fluids to stabilize me, kept me for an observation period, and advised I do not get the vaccine anymore."

Her mother had a similar reaction to influenza vaccine and her grandmother had similar reaction to tetanus vaccine. Her mother was advised not to get the COVID-19 vaccine by her physician. 

She has never had an allergic reaction to anything with PEG/polysorbate that she is aware of.

I recommended that she should pre-medicate and plan accordingly to feel unwell after the vaccine given her risk of exposure and her risk to her patients.

Answer: I fully concur with your recommendation that she should pre-medicate and plan accordingly to feel unwell after the vaccine given her risk of exposure and her risk to her patients.

  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8019658/

Question: I saw a 40-year-old male who was referred for evaluation of safety to receive a COVID-19 vaccine. His he is c/w a believed reaction two to three days after receiving H1N1 vaccine more than five years ago. Several days after this vaccine he noted yellow spots all over body and subsequent respiratory distress, intubation and extremity vascular disease requiring partial upper digit amputation. He previously tolerated flu vaccine. Autoimmune hemolysis? How would you handle this in terms of receiving COVID-19 vaccine or any vaccine for that matter?

Answer: Given that the event was more than five years ago and has not recurred since, I believe that a clinically useful work-up of this event at this time, other than an extensive review of data produced nearer to the time of the event, is not possible.

A reaction like this to a previous vaccination is not a contraindication to any of the COVID-19 vaccines currently available, or any other vaccine. Given that each flu vaccine is significantly different, and the implicated flu vaccine was from more than 5 years ago, I would consider this not to be a contraindication to receiving a flu vaccine this year.

This is one of those cases where shared decision making is essential.


Question: A 61-year-old female patient received first dose of Moderna vaccine on 3/4/21. She stayed for 30 minutes after the shot, felt tired but left to go home. On the way she felt very tired and weak. Her breathing was slow. Her husband had to help her out of the car into the house. Then she started laughing uncontrollably and had difficulty in breathing & talking. She became very incoherent. Irrelevant words came out of her mouth in response to her families' questions, even though she said she understood the questions. Finally, she went to sleep for a few hours and woke up fine that day.

Next day she felt very cold and had severe chills for about 20 minutes and extreme fatigue. The following day she felt normal. In the past she had three adverse reactions after receiving pain killers. First, at age 20, she had her wisdom tooth pulled under LA. She fell asleep in the chair and could not be woken up. She had to be carried to her car and slept for a few hours at home, and then recovered.

Second, at age 34 she was given an Epidural with Suffenta? (Fentanyl related), during labor. Within five minutes her eyes closed shut, she could not swallow and lost consciousness. She was treated and recovered consciousness in 45 minutes and baby was delivered normally.

Third episode was a few years ago, when she went to the ER for severe nosebleed. They put a balloon up her nose and gave pain killer Oxycontin. She came home and started feeling tired, weird, disoriented, and felt something bad was happening to her. After about an hour she started feeling better.

She has no known history of an adverse reaction to any vaccination. She had COVID-19 in 2020 and was sick at home for two and a half months. Can she safely take shingle and flu vaccines? Can she safely take the second COVID-19 dose? What is the relationship, if any, between the reactions to COVID-19 vaccine and pain killers?

Answer: She can safely get any herpes zoster or influenza vaccines needed. She can get the second COVID-19 mRNA vaccine dose and be observed for 30 minutes after the vaccination.

Individuals with multiple drug intolerances appear to be more likely to have benign, often subjective, adverse reactions associated with COVID-19 mRNA vaccinations.


Question: A 42-year-old female had her first Pfizer COVID-19 vaccine on 6/30/21. She felt dizzy and hot within five minutes, was observed there for 30 minutes and allowed to leave. While at home 40 minutes after the shot, she developed hives. She took Benadryl & Zyrtec and recovered completely in 24 hrs. She has no known history of adverse reactions to any vaccine in the past. She went for second COVID-19 dose on 7/22/21. Within five minutes, she was dizzy, had swelling of lips & face, and shortness of breath. She was treated with IV fluids, Benadryl, and steroids. She was observed for a few hours and then discharged on a Medrol pack. It took her a full week to recover completely.

Can she be safely skin tested for PEG/Polysorbate 20 & 80? Should she avoid taking vaccines containing PEG/Polysorbate 20 or 80? Should she avoid taking medications containing PEG, like Miralax, GoLite laxative, or any other PEG containing medicines that you can list?

Answer: Given the history provided, a clinically significant IgE-mediated allergy to polyethylene glycol and/or any polysorbate is extremely unlikely. If the patient does not have a clinical history of recurrent urticaria associated with polyethylene glycol containing foods or medications, then skin testing and/or an oral challenge to confirm current polyethylene glycol hypersensitivity is not warranted. True IgE-mediated polyethylene glycol is extremely rare.

Systemic corticosteroids are typically not helpful in treating acute urticarial episodes and may suppress development of good anti-COVID-19 T-cell mediated immunity. I would recommend only using cetirizine 10 to 40 mg a day if any future acute urticarial episodes.


Question: I have now have three patients who have a history of Influenza vaccination "anaphylaxis," with the more recent a clearly severe anaphylactic reaction three years ago. The specific influenza vaccine name unknown in each case. These patients request COVID-19 vaccination recommendations. Is COVID-19 vaccination for skin testing readily available and what would you recommend? We are going to get this question more frequently as we enter the flu season and vaccination.

Answer: There is no population-based data available that show a there is clinically significantly increased rate of anaphylaxis to any vaccination in individuals with a history of confirmed anaphylaxis to any other specific vaccine. What is well known that vaccine-associated anaphylaxis is extremely rare, on the order of 1 in 1,000,000 administrations. In general, the risk of avoiding vaccination is much larger than the risk of morbidity from vaccine-associated anaphylaxis, if an individual is being observed by a physician, or other health care provider, able to treat anaphylaxis.

It is reasonable for individuals with a history of influenza vaccine-associated anaphylaxis to undergo skin testing with the next year's influenza vaccine prior to graded administration with one hour of observation after the last dose, if skin test positive, or full dose administration and one hour of observation, if skin test negative.

Individuals with other specific vaccine-associated anaphylaxis event can be managed in similar fashion if the same exact vaccine is needed for booster immunization.

  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5026780/pdf/40413_2016_Article_120.pdf
  • https://www.jacionline.org/article/S0091-6749(17)32922-6/pdf

There is currently no role for skin testing of any kind with mRNA COVID-19 vaccines.

  • https://www.jaci-inpractice.org/article/S2213-2198(21)00713-3/fulltext

If there is still concern about intolerance to a mRNA COVID-19 vaccine, then administer a recombinant replication-incompetent Ad26 vector COVID-19 vaccine.


Question: I have a 13-year-old patient who had generalized urticaria and mild shortness of breath 40 minutes after the first Pfizer dose. Patient took antihistamines and albuterol and did not require ED visit. She is not eligible for other vaccines given age. She had a +spike IgG. Since second dose not given, her school considers her not fully vaccinated. When others at school expose her, school would require quarantine and testing. We don't have access to vaccine to give it in the clinic with AH pretreatment. Parents nervous about giving vaccine at a retail drug store. What are your recommendations?

Answer: In a large study, conducted at Sheba Medical Center in Israel, 8102 patients with allergies applied to the COVID 19 vaccine referral center and underwent risk assessment, using an algorithm that included a detailed questionnaire. Of these, high-risk patients (n = 429) were considered “highly allergic” and were immunized under medical supervision. The rate of allergic reactions to BNT162b2 vaccine, was found to be higher among patients with allergies (1.4%), particularly among a subgroup with a history of high-risk allergies. The authors concluded that administration of the mRNA vaccine is best done in a setting for immunization under medical supervision for highly allergic patients. (1)

In a study by Wolfson et al. (2), 80 individuals who reported allergic reactions after the first dose of mRNA vaccines, excipient skin testing to PEG and/or polysorbate 80 did not impact tolerance of the second dose in those with positive skin tests. 70 out of the 80 received their second dose, 62 had either no reaction or a mild reaction managed by antihistamines, although two did require epinephrine. This small study supports that the majority patients with an immediate, non-anaphylactic, allergic reaction following first mRNA vaccine can proceed with 2nd dose safely. The authors propose an interesting algorithm regarding how to proceed.

Using shared decision-making, most individuals with immediate reactions to the first dose of an mRNA COVID-19 vaccine can proceed safely with the second dose.

If concerned about an allergy to PEG, you may consider testing for this excipient. Even without a prior history, though rare, there have been reports of development of allergy to PEG on first exposure. There are recent publications addressing approaches to evaluation for potential PEG allergy. (1,3)

Since you do not have access to the vaccine, I suspect your patient’s pediatric or family practice office offers the vaccine and would provide an opportunity for supervised administration and at least a 30-minute observation period.

  1. Wolfson AR, Robinson LB, Li L, et al. First-Dose mRNA COVID-19 Vaccine Allergic Reactions: Limited Role for Excipient Skin Testing. J Allergy Clin Immunol Pract. 2021;S2213-2198.
  2. Shavit R, Maoz-Segal R, Iancovici-Kidon M, et al. Prevalence of Allergic Reactions After Pfizer-BioNTech COVID-19 Vaccination Among Adults with High Allergy Risk. JAMA Netw Open. 2021 Aug 2;4(8):e2122255. doi: 10.1001/jamanetworkopen.2021.22255. PMID: 34463744.
  3. Sellaturay P, Nasser S, Ewan P. Polyethylene Glycol-Induced Systemic Allergic Reactions (Anaphylaxis). J Allergy Clin Immunol Pract. 2021 Feb;9(2):670-675.

Question: I work at a private allergy office and we are trying to figure out what to recommend for our specific antibody deficient patients and whether or not they should be getting a booster vaccine based off of the CDC's new guidelines for immunocompromised people. I'm not sure if there's any research regarding this specific population or if there's consensus in regards to this.

Answer: The purpose of the third vaccine is to address those that had sub-optimal response to the initial series. The CDC has stated those with moderate to severe primary immunodeficiency (PIDD) should receive the booster. In my opinion, other than IgA deficiency, all patients with PIDD should be considered eligible for a third vaccine.

To my knowledge, there are no data regarding criteria for third dose in primary immunodeficiency. In fact, there are limited data specifically addressing COVID-19 vaccine response in patients with primary immunodeficiency. The NIH is conducting a large study of 400 patients with primary immunodeficiency addressing response to COVID-19 vaccine, the results of which are pending and may address your question best. Though outside the scope of your question, I have summarized the limited data that are available at this time.

Three small studies addressing the effectiveness of the mRNA COVID-19 vaccine, focusing on CVID, have been published (1, 2, 3). Most recently, Romano et. al (1), was released pre-publication in Annals of Allergy, Asthma, and Immunology (link below). This study looked at 5 CVID patients, one had had a natural infection and the remaining 4 had no detectable anti–SARS-CoV-2 antibodies before vaccination. Each patient was vaccinated with the Pfizer-BioNTech mRNA vaccine.

Postvaccination, all patients but 1 developed neutralizing antibodies against SARS-CoV-2. The patient who failed to have a substantial rise in postvaccination titers of anti–SARS-CoV-2 antibodies also had a marked decrease in the frequency of circulating B cells. They concluded that SARS-CoV-2 vaccination is safe and effective even in patients with primary antibody deficiencies. Two additional studies (2,3), reported on 6 patients and 13 patients respectively, likewise demonstrated that patients were able to mount specific antibody responses after vaccination. However, patients with absence of B cells (ie, patients with X-linked agammaglobulinemia) failed to have production of neutralizing antibodies against SARS-CoV-2. These patients did produce robust antiviral cellular responses, which still may justify vaccination.

Although the data are limited, these small studies support mRNA COVID-19 vaccination in primary immunodeficiency, with regards to safety and production of neutralizing antibodies.

References

  1. Romano C, Esposito S, Donnarumma G, Marrone A. Detection of neutralizing anti-severe acute respiratory syndrome coronavirus 2 antibodies in patients with common variable immunodeficiency after immunization with messenger RNA vaccines. Ann Allergy Asthma Immunol. 2021 Aug 2:S1081-1206(21)00523-8. doi: 10.1016/j.anai.2021.07.026. Epub ahead of print. PMID: 34352358; PMCID: PMC8327608. In Press
  2. Squire J, Joshi A. Seroconversion after coronavirus disease 2019 vaccination in patients with immune deficiency [e-pub ahead of print]. Ann Allergy Asthma Immunol. doi:10.1016/j.anai.2021.05.015, accessed June 12, 2021.
  3. Hagin D, Freund T, Navon M, et al. Immunogenicity of Pfizer-BioNTech COVID-19 vaccine in patients with inborn errors of immunity [e-pub ahead of print]. J Allergy Clin Immunol. doi:10.1016/j.jaci.2021.05.029, accessed June 12, 2021.

Question: Does anyone know how long it might take for COVID-19 anti-spike antibodies to get into the immunoglobulin supply for patients being treated for hypogammaglobulinemia? I realize that it might take quite a while, but I'm not really sure how long, and I haven't gotten a return call from the couple of companies I've called. I really don't check antibody levels but I decided to go ahead with it in one of my SIgG deficiency patients who'd been vaccinated and her #'s were great. As I know that her T-cells generally work I'd like to be able to tell whether what she has was actually made by her.

Answer: The time from acquisition of donor serum to final product takes approximately nine months. Administration of SARS-CoV-2 vaccines began mid-December 2020, eight months ago. We saw our first case of COVID-19 in the U.S. in January 2020, twenty months ago. It is almost certain there would be measurable SARS-CoV-2 antibody in current immunoglobulin product, the majority of which from natural infection rather than vaccine.


Question: Mother of a 13-year-old patient was told by their PCP that interval between two dozes of Pfizer/Moderna vaccines in this age group should be 3 months instead of 3-4 weeks and that this will reduce chances of cardiac complications due to this vaccine. Please share your opinion.

Answer: I checked the CDC and ACIP websites. At this time, there are no recommendations to increase the time interval between the doses in the at-risk population (adolescent/young adults) or anyone else. There is no data regarding whether extending the interval reduces risk. The UK has extended the interval to 12-16 weeks among adults, but the rationale has been to increase the number of persons who receive the first dose since the first dose has very good efficacy and their vaccine supply is limited. Furthermore, most of the myocarditis cases have occurred following the second injection, occur in a very small number of cases and reassuringly, have been mild.


Question: Is there any guidance for patients on low dose long-term steroids for autoimmune disease on the persistent protection of the COVID-19 vaccine? Is there any way to commercially check for persistent antibodies?

Answer: No information could be found regarding durability of antibody response in this group of patients. COVID-19 serologic tests are commercially available and there are several tests that look at various components of the virus. However, we currently do not know enough about duration of antibody response and predicting immunity. As a result, it is difficult to make conclusions about these test results. The CDC has discouraged antibody testing to assess post-vaccination immune response. A negative result does not necessarily mean that the vaccine was not successful. For now, it appears that more information is needed before these tests are ready for use outside of the research arena.


Question: If a patient has had COVID-19 infection and recovered, do they need to be vaccinated? Should we check IgG to COVID-19 virus first and if not in protective range, then give the vaccine? How long should a person wait who had COVID-19 infection before getting the COVID-19 vaccine?

Answer: Yes. The COVID-19 vaccine is recommended in a patient that has a history of COVID-19, as recurrent infections have been reported. Several studies involving small numbers of patients have indicated that immune responses after a single dose of mRNA vaccine produces levels comparable to those in infection-naïve patients after two doses. This study confirmed that finding in more than 1,000 people. There is no need to check antibody levels. People with COVID-19 who have symptoms should wait to be vaccinated until they have recovered from their illness and have met the criteria for discontinuing isolation; those without symptoms should also wait until they meet the criteria before getting vaccinated. This guidance also applies to people who get COVID-19 before getting their second dose of vaccine. If your patient was treated for COVID-19 with monoclonal antibodies or convalescent plasma, he/she should wait 90 days before getting a COVID-19 vaccine.

For more information, please refer here (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/faq.html).


Question: Does the Janssen (Johnson & Johnson) vaccine contain PEG?

Answer: No. The Janssen COVID-19 vaccine includes the following ingredients: recombinant, replication-incompetent adenovirus type 26 expressing the SARS-CoV-2 spike protein, citric acid monohydrate, trisodium citrate dihydrate, ethanol, 2-hydroxypropyl-β-cyclodextrin (HBCD), polysorbate-80, sodium chloride. You can view the vaccine fact sheet here. (https://www.janssenlabels.com/emergency-use-authorization/Janssen+COVID-19+Vaccine-Recipient-fact-sheet.pdf)


Question: I reviewed the FAQ section on the AAAAI COVID-19 resources for clinicians, and I did find your advice on the use of daily oral steroids and interaction with the COVID-19 vaccine. I have a 68 yo male patient who has received 80mg of kenalog intra-articularly recently, and will be 11 days out of the intra-articular injection by the time he receives his first COVID-19 vaccine. For patients receiving long-acting steroid regimens, would you recommend a 4 week vs 2 week waiting period prior to the vaccine, if possible?

Answer: It depends on whether this was a depot steroid injection or an immediate acting injection. If immediate acting, I think that two weeks is reasonable. Immune suppression with corticosteroids usually requires several weeks of therapy, although depot injections can sustain the steroid dose for up to 6 weeks.  In that case, receiving the vaccine as soon as possible is preferred, before the immunosuppression begins.


Question: What recommendations can be given to patients who have been vaccinated regarding what they should do if exposed to a person with COVID-19?

Answer: Vaccinated persons with an exposure to someone with suspected or confirmed COVID-19 are not required to quarantine if they meet all of the following criteria: 

  • are fully vaccinated (two weeks or more after the final vaccine dose), 
  • are within 3 months following receipt of the final dose,
  • and have remained asymptomatic since the current exposure. 

Question: Should a patient who takes Singulair and Symbicort discontinue these medications two weeks prior and two weeks after the COVID19 vaccine? If these medications modify the immune system should these medications be held? 

Answer: No, there is no impact on an individual’s ability to respond to the vaccine and control of asthma is essential! There is no data to suggest that inhaled corticosteroids and/or leukotriene receptor antagonists impact on immunogenicity of the mRNA COVID-19 vaccines.


Question: CDC recommendations say not to pre-treat with antihistamines so as to not “mask” a reaction. However, I think for those patients that have known allergies or a background of allergies, pre-treatment makes sense. We tell patients to pre-treat before immunotherapy, to pre-treat before Aspirin desensitization, and pre-treat in some cases before OIT. Antihistamine pretreatment can blunt the severity of a reaction and buy time in management, which might be an advantage in venues where the vaccine is being given by personnel who are not trained in allergy management. Why not pre-treat before the vaccine in patients that have a background of allergy? 

Answer: Antihistamines are not contraindicated and can be given before the vaccination, although this approach is not recommended as a routine. One can make arguments either way as to whether this would hide or prevent a more serious reaction. In cases where the vaccine is administered without immediate availability of medical expertise, I would be concerned that the staff might miss a serious reaction if initial symptoms are blunted by the administration of the antihistamine before the vaccination.


Question: I assume with high dose steroids (>20mg/day) for prolonged periods, that the COVID vaccine should be deferred until at least several weeks. Any guidance with low dose or IM steroids and timing of COVID-19 vaccine?

Answer: Daily oral steroids may interfere with the antibody response to the vaccine based on data with other immunosuppressives and flu vaccine. If the dose can be safely stopped, then waiting two weeks may be a reasonable approach. If the steroids cannot be stopped, we would not delay administration of the vaccine as the risks associated with COVID infection outweigh the potential impaired response.


Question: Should a patient delay allergen immunotherapy (AIT) because they are receiving one of the mRNA COVID 19 vaccines?

Answer: The COVID 19 Task Force does not anticipate any contraindication for patients on AIT. However, it would be best to not get the two shots within 48 hours of each other to avoid confusion should a reaction occur.


Question: Is there any cross-reactivity between gelatin and PEG? I have a patient who experienced anaphylaxis to gelatin in vaccine and foods. Is she likely to react to the COVID-19 vaccines? 

Answer: There is no gelatin in either the Pfizer or Moderna vaccine. To my knowledge there is no cross reactivity between PEG and gelatin. PEG is not found in other vaccines, except for Hepatitis A. If she had anaphylaxis to a vaccine other than the Pfizer or Moderna, then a 30-minute observation period is recommended. 


Question: We are a large Allergy and Asthma group and many patients, due to the new vaccine, are asking if we test for polyethylene glycol and polysorbate. Is there a protocol in place for this? Your information on this matter will be greatly appreciated.

Answer: Our Task Force would not recommend routine skin testing for PEG in patients prior to vaccination unless they have a history of a severe allergic reaction to an injectable medication, or a history of a possible reaction to PEG. Skin testing is not standardized and the predictive value of skin testing is not known. Skin testing to PEG has been associated with systemic reactions. Furthermore, it is still not known if an allergy to PEG is the reason for allergic reactions to the SARS-CoV-2 vaccine. Routine testing, given these unknowns, may exclude people from receiving the vaccine unnecessarily, but could also potentially clear a patient for the vaccine who could still have a reaction. We refer you to 2 articles from JACI-IP in the last 2 years that may offer more insight: Polyethylene Glycol: Not Just a Harmless Excipient (jaci-inpractic e.org) and Polyethylene Glycol-Induced Systemic Allergic Reactions (Anaphylaxis) (jaci-inpractice.org)


Question: As a practicing Allergist/ Immunologist, I perform patch testing at my office for the evaluation of contact dermatitis/ urticaria. Over the years, I have noticed that several patients have positive patch tests to PEG, one of the components of the Pfizer and Moderna COVID-19 vaccines. Indeed, when eliminating products that contain PEG, the skin symptoms abate. What advice shall I give these patients in terms of whether to receive the now available vaccines, or not? Please note that some of these patients have severe contact allergies to PEG.

Answer: We would suggest that the patient be skin tested for an IgE-mediated reaction to PEG. Contact dermatitis secondary to PEG is not IgE-mediated, so we don’t know what the risk would be for vaccination. The patient should also be queried about systemic reactions to medications or products that contain PEG.


Question: How should we treat patients with mastocytosis and the COVID Vaccines?

Answer: We do not see a contraindication for COVID 19 vaccination for mastocytosis patients. These patients would likely be in to the 30 minute wait group as they may have had a history of anaphylaxis (to any cause) separate from an mRNA vaccine or excipient in the vaccine.


Question: I am giving COVID-19 Pfizer vaccines at our hospital. We have had two anaphylaxis to date. Because this will be their only injection of that dosage based upon CDC guidelines, and with paucity of data on benefits of IV or oral steroid in anaphylaxis immediate care: Should we be looking at recommendation to avoid steroids in treating these patients with anaphylaxis? Most respond readily to 1-2 doses of epinephrine thus far. Steroids may blunt any precious antibody response?

Answer: In general, steroids are not needed or indicated for treatment of anaphylaxis. Treatment should be injectable epinephrine. Indeed, the recent practice parameters indicate no proven utility for use of steroids in acute anaphylaxis (J Allergy Clin Immunol. 2020;145(4):1082-123). Therefore, in response to this question, the answer would be to not administer steroids, but to treat the anaphylaxis with injectable epinephrine.


Question: What advice should we give patients who are allergic to several medications about the COVID-19 vaccine?

Answer: At the date of this response (December 19, 2020), only the Pfizer-BioNTech COVID-19 is available for administration in the U.S.   This is a dynamic process, so stay current on any changes in recommendations.  A summary of current recommendations are as follows:

Patients with allergies to oral medications (including oral equivalent of injectable medications), foods, insect, latex and environmental allergens have no restrictions and are recommended to receive the vaccine, followed by a 15-minute observation period.

Patients with non-serious reactions to vaccines or other injectables also have no restrictions, and are recommended to receive the vaccine, followed by a 15-minute observation period.

Patients with a history of severe allergic reactions (eg anaphylaxis) to vaccines (other than Pfizer-BioNTech COVID-19) or history of severe allergic reaction to any injectable medication, should be assessed for risk.  The CDC ACIP suggests considering potential deferral of vaccination, and to observe for 30 minutes, if vaccination is given.

Patients with a history of severe allergic reactions (eg anaphylaxis) to any component of the Pfizer-BioNTech or Moderna vaccines should not receive the vaccine.

In all cases, equipment and medications should be available to treat any potential anaphylactic event.


Question: I’m trying to research if there’s any guidance on patients receiving immunotherapy for their allergies and getting the COVID vaccine. Specific question I have would be: Should allergy shots be held for any amount of time before or after the COVID vaccine?

Answer: We do not anticipate any contraindication for patients on AIT. However, it would be best to not get the 2 shots within 48 hours of each other to avoid confusion should a reaction occur.


Question: I have a patient that was diagnosed with COVID-19 one month ago. She has had long-standing, uncontrolled allergic rhinoconjunctivitis, and she would like to start allergen immunotherapy. Would there be any reason to suggest a certain waiting interval after her diagnosis before starting AIT?

Answer: Provided your patient had a mild, uncomplicated clinical course of COVID there is no reason to delay immunotherapy. On the other hand, if your patient had a more severe course or is immunocompromised, then viral shedding can continue for >28 days. Aydillo T, et al. (1) reported that some immunocompromised people may shed infectious novel coronavirus for at least two months after diagnosis, rather than the 10 days demonstrated in uncomplicated cases. The patients in the study had become immunocompromised after receiving stem cell transplantation, immunosuppressive therapy, or chemotherapy for various cancers. I feel that we can apply this rationale to other immunocompromised conditions.

1) Aydillo T, Gonzalez-Reiche AS, Aslam S, van de Guchte A, Khan Z, Obla A, Dutta J, van Bakel H, Aberg J, García-Sastre A, Shah G, Hohl T, Papanicolaou G, Perales MA, Sepkowitz K, Babady NE, Kamboj M. Shedding of Viable SARS-CoV-2 after Immunosuppressive Therapy for Cancer. N Engl J Med. 2020 Dec 1. doi: 10.1056/NEJMc2031670. Epub ahead of print. PMID: 33259154

2) https://www.nejm.org/doi/full/10.1056/NEJMc2031670


Question: If a patient has had COVID19 infection and recovered, then do they even need the vaccine? Or should we check IgG to COVID19 virus first and if not in protective range then give the vaccine?

Answer: Yes. The COVID Vaccine is recommended in a patient that has a history of COVID. There is no need to check antibody. Recurrent infections have been reported. It is felt that the vaccine will provide superior protection.


Question: Post Covid we have been using albuterol inhaler for doing pre- and post-spirometry. There is discrepancy as how many puffs (2 or 4) of albuterol inhaler we use prior to post bronchodilation spirometry?

We have been using 4 puffs (1 puff each 1 minute apart) waiting 10 minutes before doing post bronchodilation spirometry. Wondering if this any data to validate that dosing and timing?

Answer: You are correct, although 30 seconds in between would be adequate, rather than 1 minute.

Sim YS, Lee JH, et al. (1) provide a very thorough review of pre- and post-bronchodilator spirometry. The recommended procedure for albuterol is as follows. In the albuterol (short-acting β2-bronchodilator) bronchodilator test, the subject fully exhales slowly, and sprays an albuterol metered dose of 100 µg (1 puff) while biting a valved chamber. The subject then slowly and deeply inhales until reaching TLC over 3–5 seconds, holds the breath for 5–10 seconds, and exhales. This procedure is repeated four times (total 400 µg of albuterol), at intervals of 30 seconds. After inhalation of the last medication, the spirometry test is conducted again between 10–20 minute (1)

Also relevant to your question is this technique appropriate in a post-COVID patient. Grandbastien M, Piotin A, et al. (2) published an exceptional paper in J Allergy Clinical Immunology Practice. They studied 106 patients with SARS-CoV-2 between March 4 and April 6, 2020, who were hospitalized in the Chest Diseases Department of Strasbourg University Hospital; 23 had asthma.

The authors did not observe any increase in severe exacerbation with the development of SARS-CoV-2 pneumonia. This result is not in line with other respiratory viruses, such as Rhinovirus. In contrast to other respiratory viruses, SARS-CoV-2 may not be a risk factor for severe asthma exacerbation.

They further report that several hypotheses can be raised. ACE2 has been shown to be the functional receptor of SARS-CoV-1. This receptor is abundantly expressed in type I and type II pneumocytes, whereas bronchial epithelial cells exhibit only weak staining.

This study suggests that the risk factors for hospitalization in asthmatic patients were related more to the risk factors of SARS-CoV-2 pneumonia than to asthma.

In summary, in contrast to other viral respiratory infections, SARS-CoV-2 pneumonia did not appear to induce severe asthma exacerbation.

References:

1) Sim YS, Lee JH, Lee WY, et al. Spirometry and Bronchodilator Test. Tuberc Respir Dis (Seoul). 2017;80(2):105-112. doi:10.4046/trd.2017.80.2.105

2) Grandbastien M, Piotin A, Godet J, et al. SARS-CoV-2 Pneumonia in Hospitalized Asthmatic Patients Did Not Induce Severe Exacerbation. J Allergy Clin Immunol Pract. 2020;8(8):2600-2607. doi:10.1016/j.jaip.2020.06.032


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