Getting the Basics Right in Allergy Care

In this journal and other allergy specialty journals, we often read about important scientific breakthroughs with potential to improve the lives of people affected by allergic conditions. This month, we highlight areas where attention to ‘the basics’ is all that is needed to improve the clinical care of people with allergies. The first Editor's Choice article explores patterns of adrenaline auto-injector prescribing in England. Adrenaline auto-injectors are medical devices which aim to promptly reverse symptoms of anaphylaxis and potentially prevent fatal outcome. Their design, dosing, indications and effectiveness have all attracted debate and controversy [1, 2]. But since their licensing in 1989 they have become an allergy must-have item and a commercial success story. Although there is considerable uncertainty about dosing, it is likely that the treatment dose for larger, older children and adults should be higher than the dose for younger children. Michaelis et al. show us that in community practice, prescription of inappropriately low dose adrenaline auto-injectors is relatively common [3]. In an analysis of 2 years of prescribing data for England, the authors found over 1700 patients, mainly adults, were prescribed a low-dose (150 μg) adrenaline autoinjector. Using national resuscitation council guidance, they estimated that up to half of all 150 microgram prescriptions may have been underdosed. This adds to the known issue that in many regions there is no availability of 500 microgram adrenaline auto-injectors, meaning that ‘correct’ prescription of 300 microgram devices could also be considered to represent underdosing. Clearly further work is needed to ensure more robust prescribing guidance, but checking a patient's weight and the relevant adrenaline dose before issuing a repeat prescription seems like a relatively simple step for clinical practitioners to make (Figure 1). The second article suggesting a need to get the basics right concerns hospital-based documentation of allergy in electronic health records [4]. Qiyu et al. used freedom of information requests to ensure a high rate of response to their survey of public health system hospitals in the United Kingdom. They found widespread evidence of inadequate technological support in hospital systems for documenting known allergies in patients. A very wide variety of electronic reporting systems was used between, and even within, each hospital group. It was not uncommon to find hospitals using electronic systems which simply couldn't capture certain types of allergies—for example, over half of hospital trusts had no category for recording food allergy incidents. In their analyses, Qiyu et al. found associations between inadequate electronic reporting systems and incidents of patients being exposed to known allergens. They also carefully documented cases of harm caused by inadequate documentation at a single hospital trust, where there was about 1 case of preventable moderate harm each year due, in part, to inadequate documentation of a known allergy. This study highlights the importance of getting adequate electronic health record systems in place and harmonising approaches across regions and nations to better protect people with allergies from inadvertent exposure to known allergens in healthcare settings (Figure 2). In clinical practice, we are often encouraged to purchase the latest equipment and ensure that our patients have access to more expensive diagnostics or treatments. In our third Editor's Choice article this month, Noble et al. evaluate one such diagnostic test—fractional exhaled nitric oxide (FENO). They explore the diagnostic value of this commonly used clinical test, to detect a clinically significant change in asthma control in two populations of adults with asthma [5]. The group used two clinical trial populations of well-phenotyped adults with asthma who underwent repeated measures of FENO and asthma control. They found change in FENO had poor diagnostic performance for detecting a clinically important change in asthma-related quality of life. Sensitivity and specificity were 47% and 57% respectively, using a commonly recommended cut-off for change in FENO. This doesn't mean we should all stop using nitric oxide measurements in clinical practice since there is evidence that FENO-guided practice may reduce asthma exacerbations [6]. However, the findings do highlight the weakness of any relationship between change in FENO and quality of life in adults with asthma. R.J.B. drafted the manuscript. M.H.S. approved the manuscript. The authors declare no conflicts of interest.