All of the JTF Practice Parameters are available in PDF for downloading. Just follow the links below to the download page for each disease state.
The updated Anaphylaxis Parameter discusses the approach to the management of a patient who is referred to the allergist/immunologist’s office for evaluation after experienced an anaphylactic episode and the management of anaphylaxis when it occurs in the physician’s office. In addition, this document includes guidelines for managing patients in regard to specific causes of anaphylaxis, such as anaphylaxis due to foods, latex, exercise, medications, biologic agents, insect stings, and immunotherapy, as well as anaphylaxis in the peri-operative period, seminal fluid anaphylaxis and idiopathic anaphylaxis.
Zuraw BL, Bernstein JA, Lang DM, Craig T, Dreyfus D, Hsieh F, et al. A focused parameter update: Hereditary angioedema, acquired C1 inhibitor deficiency, and angiotensin-converting enzyme inhibitor-associated angioedema. The Journal of allergy and clinical immunology. 2013 Jun;131(6):1491-3 e25. PubMed PMID: 23726531.
This focused Practice Parameter provides an evidence-based approach to the diagnosis and management of non-histaminergic angioedema, of which most have been well established to be caused by bradykinin -- including hereditary angioedema (HAE) types I and II, Acquired angioedema and ACE induced angioedema. It also provides an updated discussion of HAE with normal complement with or without a genetic component (previously referred to as HAE type III), for which the mechanism is not well understood. The pathogenesis of HAE and other bradykinin-mediated forms of angioedema is also included. Treatment recommendations based on best evidence are included; traditional and novel agents for management of HAE are reviewed. This replete parameter is an excellent guide for the allergist/immunologist who encounters angioedema in their office.
Pathogenesis, prevalence, diagnosis, and management of exercise-induced bronchoconstriction: a practice parameter. Weiler JM, Anderson SD, Randolph C, Bonini S, Craig TJ, Pearlman DS, et al. Ann Allergy Asthma Immunol. 2010 Dec;105(6 Suppl):S1-47.
The objective of Attaining optimal asthma control: a practice parameter; is to stress a paradigm shift from asthma assessment based upon severity to that of control. It stresses that assessment of asthma control at every clinic visit, with a physician determination of asthma control as either well controlled or not well controlled as the cornerstone of care in the asthmatic patient. As detailed in the algorithm of care, management decisions can then be driven by the level of asthma control. Assessment and targets of asthma control then relies on a step-up and step-down approach to pharmacotherapy. Perhaps more importantly, control-driven asthma guidelines encompass the principles of chronic disease management, including periodic assessment, goal (outcome) orientation, and individualization of therapy.
This algorithm on the diagnosis and treatment of asthma is intended to complement and update the previously published Practice Parameters for the Diagnosis and Treatment of Asthma. Both documents were developed by the Joint Task Force on Practice Parameters, representing the AAAAI, ACAAI, and the JCAAI. The authors of this asthma algorithm have attempted to include all the elements essential for the diagnosis and care of patients with asthma. Every effort was made to keep the algorithm clear and concise, yet thorough and complete. Each component of the algorithm is elaborated further in a brief annotation. For further discussion, the reader is referred to the more extensive Practice Parameters for the Diagnosis and Treatment of Asthma.
This parameter builds upon the foundation of the NHLBI asthma report and extends the concept of guideline-driven asthma management. The development of this practice parameter was the result of a work group, the Joint Task Force, and selected reviewers who incorporated evidence into this guideline, thereby providing the practicing allergist an updated, practical, guide for the assessment and management of asthma. All physicians caring for patients with asthma, e.g., allergists, primary care physicians, and pulmonologists, should benefit from this updated practice parameter. This new practice parameter will provide a time-efficient method for all physicians to increase their knowledge base and/or confirm their current clinical approach to caring for patients with asthma. Starting with a simplified algorithm of care, the physician should next review the eleven summary statements and referenced Executive Summary which validates the importance of this change in paradigm form treatment based upon severity to that treatment based upon asthma control. For more in-depth review and study, the reader can progress to the "Summary Statements with Discussion" and the 49 references provided.
Atopic dermatitis is an important component of the atopic diathesis. It not only frequently accompanies allergic respiratory disease but often is the first manifestation of allergic disease. Most patients with atopic dermatitis will develop allergic rhinitis or asthma. The evaluation and management of atopic dermatitis are, therefore, an integral part of an allergist/immunologist’s training and practice. It is also important for the primary care physician to understand the basis for effective evaluation and management of patients with this condition, since atopic dermatitis affects more than 10% of children and can have a significant impact on the patient’s quality of life. As discussed in this document, it is also important for the primary care physician to know when to appropriately consult a specialist in atopic dermatitis.
Atopic dermatitis is an important manifestation of the atopic diathesis. It not only frequently accompanies allergic respiratory disease but often precedes it as the initial clinical manifestation of allergic disease. The evaluation and management of patients with atopic dermatitis is therefore an integral part of an allergist’s practice and training. Since atopic dermatitis affects more than 10% of children, it is important for the primary care physician/ provider to be familiar with the evaluation and management of this common skin condition, and know when to consult a qualified subspecialist, particularly when the diagnosis may not be established.
Contact dermatitis (CD) encompasses all adverse cutaneous reactions that result from the direct contact of an exogenous agent (a foreign molecule, UV light, or temperature) to the surface of the skin or mucous membranes. The skin can react immunologically and/or nonimmunologically to such exogenous agents. The inflammatory process that results from an allergic substance is mediated through immunologic mechanisms, whereas irritant reactions result from direct tissue damage, which initiate alternative inflammatory reactions. However, the distinction between allergic contact dermatitis (ACD) and irritant contact dermatitis (ICD) has become increasingly blurred. Often these exogenous forms of dermatitis must be distinguished from endogenous dermatitis (e.g., atopic dermatitis, nummular eczema, dyshidrosis). It is not unusual for an exogenous dermatitis to be superimposed on an endogenous eruption, most commonly encountered when compresses or topical antibiotics are used too long on barrier-impaired skin.
Adverse drug reactions are a major health problem in the United States. About 25% of all adverse drug reactions have an allergic, pseudoallergic, or idiosyncratic/intolerant basis. Idiosyncratic drug reactions and drug intolerance are also included in this category. Drug allergy may be classified by the Gell and Coombs classification of human hypersensitivity (Type 1: IgE-mediated; Type 2: cytotoxic; Type 3: immune complex; and Type 4: cellular immune mediated). Drug allergy is also frequently characterized by the predominant tissue/organ involved (systemic, cutaneous, or visceral). To some extent, the structural characteristics of drugs and biologic products predict the type of hypersensitivity reaction.
The objective of “Drug Allergy: An Updated Practice Parameter” is to improve the care of patients by providing the practicing physician with an evidence-based approach to the diagnosis and management of adverse drug reactions. This parameter builds on “Disease Management of Drug Hypersensitivity: A Practice Parameter,” which was published in 1999 by the Joint Task Force on Practice Parameters. It follows the same general format as that document, with some substantive changes reflecting advancements in scientific knowledge and their effect on management of drug allergy.
Portnoy J, Miller JD, Williams PB, Chew GL, Miller JD, Zaitoun F, et al. Environmental assessment and exposure control of dust mites: a practice parameter. Ann Allergy Asthma Immunol. 2013 Dec;111(6):465-507
Jay Portnoy, MD, Ginger L. Chew, ScD, Wanda Phipatanakul, MD, et al. ‘‘Environmental assessment and exposure control of cockroaches: JACJ a practice parameter’’. J Allergy Clin Immunol. In press 2013 Aug. [Full Parameter]
The Cockroach Practice Parameter is the third in a series of practice parameters that address the effect of the environment on allergies and asthma. The first two, furry animals, and rodents, were published in 2012. Additional ones to follow include dust mites, fungi, and irritants. Recommendations on environmental control of cockroaches are made to keep exposure as low as possible to prevent sensitization, prevent development of disease, and reduce ongoing morbidity in sensitized persons. What we do not know is whether interventions that keep exposure low are as effective at improving health as simply living in an environment with naturally low exposure from the beginning. As discussed in further detail in this practice parameter, indoor levels of less than 2 U/g Bla g 1 or 2 U/g Bla g 2 (which is equivalent to 0.08 mg/g Bla g 2) are associated with a lower risk of sensitization and
symptoms on exposure.
Phipatanakul W, Matsui E, Portnoy J, Williams PB, Barnes C, Kennedy K, et al Environmental assessment and exposure reduction of rodents: a practice parameter. Ann Allergy Asthma Immunol 109 (2012) 375e387. [Full Parameter]
The objective of the Food Allergy: A practice parameter is to improve the care of patients with food allergy by providing the practicing physician with and evidence-based approach to the diagnosis and management of IgE-mediated (allergic) food reactions. Following a thorough review of the medical literature, the work group, the Joint Task Force, and selected reviewers incorporated this information into this guideline, thereby providing the practicing allergist an current, practical, guide for the diagnosis and management of food allergy.
All physicians caring for patients with food allergy, e.g., allergists, primary care physicians, and gastroenterologists, should benefit from this practice parameter. This practice parameter will provide a time-efficient method for all physicians to increase their knowledge base and/or confirm their current clinical approach to caring for patients with food allergy. This parameter is comprised of 105 summary statements and referenced Executive Summary which incorporates the literature in an “evidence-based” fashion regarding the diagnosis and management of food allergy. For more in-depth review and study, the reader can progress to the "Summary Statements with Discussion" and the 682 references provided.
Primary immunodeficiencies are inherited disorders of immune system function that predispose affected individuals to increased rate and severity of infection, immune dysregulation with autoimmune disease, and malignancy. The purpose of this Practice Parameter for the Diagnosis and Management of Primary Immunodeficiency is to provide the consultant allergist/immunologist with a practical guide for the clinical recognition and diagnosis of immunodeficiency, along with the general principles that guide management of these disorders. The first Parameter for Primary Immunodeficiency was published in 1996. This document represents the first major revision since its original publication. Primary immunodeficiencies have many clinical similarities with, but are distinct from, secondary immunodeficiencies that may occur during certain viral infections, after immunosuppression to prevent graft rejection after transplantation, during treatment of systemic autoimmune disease, or in association with cancer chemotherapy. More than 100 distinct genetic disorders that affect immune system function have been identified to date. Primary immunodeficiencies occur in as many as 1 in 2,000 live births. They are most often categorized according to the immune mechanisms that are disrupted. These categories include the defects of specific immunity that are subdivided into humoral or antibody deficiencies, cellular deficiencies, and the combined deficiencies that affect both humoral and cellular mechanisms. There are also defects of innate immunity and the phagocyte and complement system defects. Of all of these categories, antibody deficiencies together account for approximately half of all primary immunodeficiency.
Congenital immunodeficiency usually (but not always) has a characteristic appearance in infants, children, and adults according to the sex of the child, age of the patient, immunization history with live vaccines, and exposure to infections. Recurrent, serious infection, especially with encapsulated organisms is the hallmark of humoral immunodeficiency. Family history, particularly of affected males, is extremely important in the diagnosis of immunodeficiency. Physical examination of the patient is essential with attention to failure-to-thrive, weight loss, enlargement or absence of lymph nodes, organomegaly, dermatitis, oral candidiasis, short stature, clubbing, and listlessness.
The objective of Allergen immunotherapy: A practice parameter second update is to establish guidelines for the safe and effective use of allergen immunotherapy for patients with allergic rhinitis, allergic asthma, and Hymenoptera sensitivity. This document builds on the previous Joint Task Force document, Allergen immunotherapy: a practice parameter published in the Annals of Allergy, Asthma and Immunology in 2003. The updated practice parameters draft was prepared by Drs Linda Cox, James Li, Hal Nelson, and Richard Lockey. The Joint Task Force reworked the initial draft into a working draft of the document. The project was exclusively funded by the 3 allergy and immunology societies noted above. Topics covered in this parameter include: indications and contraindications, extract selection and dosing, mechanisms, schedules, safety, and novel approaches. This parameter also includes examples of immunotherapy prescription and administration forms and documentation guidelines.
The objective of Allergen immunotherapy: a practice parameter is to improve the practice of allergen immunotherapy for patients with allergic rhinitis, allergic asthma, and Hymenoptera sensitivity. This parameter is intended to increase the appropriate use of allergen immunotherapy; reduce the underuse, overuse, and misuse of allergen immunotherapy; and establish guidelines for the safe and effective use of allergen immunotherapy, while reducing unwanted and unneeded variation in immunotherapy practice.
Stinging Insect Allergy
Golden DB, Moffitt J, Nicklas RA, Freeman T, Graft DF, Reisman RE, et al. Stinging insect hypersensitivity: A practice parameter update 2011. J Allergy Clin Immunol. 2011 Apr;127(4):852-4 e23. [Full Parameter]
The objective of Stinging Insect Hypersensitivity: A practice parameter update is to improve the care for patients with stinging insect hypersensitivity. This parameter is intended to refine guidelines for the use and interpretation of diagnostic methods and for the institution and implementation of measures to manage stinging insect hypersensitivity, with particular emphasis on the appropriate use of immunotherapy.
Anaphylaxis from insect stings results in a significant number of fatalities each year. At least 40 deaths occur in the United States yearly from reactions to insect stings, and it is likely that additional deaths are unrecognized and therefore not reported. Data indicating the prevalence of fatalities from insect stings can never adequately reflect the individual tragedy associated with the sudden and unexpected loss of a friend or relative. Although most insect stings produce only local discomfort, potentially life-threatening reactions occur in both children and adults.
The objective of the Diagnosis and Management of Rhinitis: An Updated Practice Parameter is to improve the care of patients with all types of rhinitis, with an emphasis on allergic rhinitis. Following a thorough review of the recent medical literature published since the 1998 Rhinitis Practice Parameter, the work group, the Joint Task Force, and selected reviewers incorporated this evidence into this guideline thereby providing the practicing allergist an updated, practical, guide for the diagnosis and management of rhinitis.
All physicians caring for patients with rhinitis, e.g., allergists, primary care physicians, and otolaryngologists, should benefit from this updated practice parameter. This new practice parameter will provide a time-efficient method for all physicians to increase their knowledge base and/or confirm their current clinical approach to caring for patients with rhinitis. Starting with the table of “key updates”, (The 1 minute read.) the physician should next review the 108 summary statements and referenced Executive Summary which incorporates the most significant changes in rhinitis diagnosis and management. (The 45 minute read.) User-friendly charts, algorithms, and tables will serve as a quick reference during daily practice. For more in-depth review and study, the reader can progress to the Summary Statements with Discussion and the 998 references provided.
The Joint Task Force on Practice Parameters has developed a method for assessing severity of symptoms of allergic rhinitis, which is outlined in this article. The system is designed as an extension of the Practice Parameter on Rhinitis published in November 1998. This article is divided into 2 parts. Part 1, which is published herein, includes evaluations of (1) nasal symptom severity; (2) nonnasal symptom severity; (3) global nasal and nonnasal symptom severity; (4) quality-of-life issues related to allergic rhinitis; (5) the impact of current and past rhinitis medications in the evaluation of allergic rhinitis severity; and (6) the influence of concomitant medications on allergic rhinitis severity.
Sinusitis is one of the most commonly diagnosed diseases in the United States, affecting an estimated 16% of the adult population annually. It extracts an overall direct annual health care cost of $5.8 billion. Total restricted activity days increased from 50 million per year during 1986 through 1988 to 73 million per year during 1990 through 1992. Sinusitis also significantly affects quality of life in some symptom domains even more than other chronic diseases, such as chronic obstructive pulmonary disease, angina, and back pain.
Sinusitis develops in approximately 31 million Americans each year. An average of 4 days are lost from work each year because of acute sinusitis. Acute sinusitis typically follows a viral upper respiratory infection or an allergic reaction. Swelling of the nasal mucous membranes may obstruct drainage from the sinus outflow tracts, causing mucus to collect in the paranasal sinuses. This pool of retained secretions may become infected, leading to congestion and inflammation of the sinus mucosa and the classic symptoms associated with sinusitis. Treatment is aimed at killing the overgrown bacteria and cleansing the sinuses.
Allergy Diagnostic Testing
The overall objectives of this Parameter on Allergy Diagnostic Tests are tripartite: (1) to develop a reliable reference resource for selecting appropriate diagnostic tests; (2) to provide guidelines and support for the practicing physician on how diagnostic tests should be used in an appropriate and cost-effective manner; and (3) to improve the quality of care of patients by facilitating prompt and accurate diagnosis of their hypersensitivity disorders. The major emphasis of this updated version of Practice Parameters for Allergy Diagnostic Testing is focused on how technological refinements and their validations during the past decade are being incorporated into the diagnostic armamentarium of allergists/clinical immunologists and how their optimal use enables confirmation of human clinical sensitivity. The term allergy in this Practice Parameter denotes major categories of human hypersensitivity. Pertinent clinical immunologic techniques are oriented to this category of adaptive immunity but not to infection, cancer, or transplantation immunology.
The purpose of the Workgroup on Practice Parameters for Allergy Diagnostic Testing was to formulate an outline of the rational basis for proper use and interpretation of the most important clinical and laboratory tests used by allergists. This should serve not only to confirm the presence of allergic factors but also guide the proper choice of therapy. The American Academy of Allergy, Asthma, Immunology (AAAAI) and the American College of Allergy, Asthma, and Immunology (ACAAI) have jointly accepted the responsibility for establishing allergy diagnostic parameters in order to pro-mote advancement and improvements in care for 35 million allergic patients and facilitate the education of physicians who care for them.
Kelso JM, Greenhawt MJ, Li JT, Nicklas RA, Bernstein DI, Blessing-Moore J, et al. Adverse reactions to vaccines practice parameter 2012 update. J Allergy Clin Immunol. 2012 Jul;130(1):25-43.[Full Parameter]
Administering influenza vaccine to egg allergic recipients: a focused practice parameter update. Greenhawt MJ, Li JT, Bernstein DI, Blessing-Moore J, Cox L, Khan D, et al. Ann Allergy Asthma Immunol. 2011 Jan;106(1):11-6. [Full Parameter]
This practice parameter provides a practical, peer-reviewed, evidence-based guide for evaluation and management of patients with suspected allergy to vaccines. The practice parameter offers both general and vaccine-specific recommendations for skin testing to vaccines and components, serum specific IgE in vitro antibody testing, serologic testing for protective antibody responses to vaccines, vaccine administration, and avoidance. The guidelines should prove useful for primary care physicians and specialists in allergy and immunology. More importantly, most patients who avoid vaccination because of allergy concerns will be able to receive their appropriate vaccinations if this practice parameter is followed.
The 2 key points of the practice parameter are that (1) patients with suspected allergy to vaccines or vaccine components should be evaluated by an allergist/immunologist and (2) most patients with suspected allergy to vaccines can receive vaccination safely. With the recent worldwide concerns about H1N1 influenza, interest in the health benefits of vaccination is greater than ever. Our hope is that this publication will result in safe vaccination for patients with suspected allergy to vaccines.